The clinical value of ultrasound in the assessment of the severity of COVID-19

Background: Lung injury is a common condition among hospitalized patients with coronavirus disease 2019 (COVID-19). However, whether lung ultrasound (LUS) score predicts all-cause mortality in patients with COVID-19 is unknown. The aim of the present study was to explore the predictive value of lung ultrasound score for mortality in patients with COVID-19.Methods: Patients with COVID-19 who underwent lung ultrasound were prospectively enrolled from three hospitals in Wuhan, China between February 2020 and March 2020. Demographic, clinical, and laboratory data were collected from digital patient records. Lung ultrasound scores were analyzed offline by two observers. Primary outcome was in-hospital mortality.Results: Of the 402 patients, 318 (79.1%) had abnormal lung ultrasound. Compared with survivors (n = 360), non-survivors (n = 42) presented with more B2 lines, pleural line abnormalities, pulmonary consolidation, and pleural effusion (all p < 0.05). Moreover, non-survivors had higher global and anterolateral lung ultrasound score than survivors. In the receiver operating characteristic analysis, areas under the curve were 0.936 and 0.913 for global and anterolateral lung ultrasound score, respectively. A cutoff value of 15 for global lung ultrasound score had a sensitivity of 92.9% and specificity of 85.3%, and 9 for anterolateral score had a sensitivity of 88.1% and specificity of 83.3% for prediction of death. Kaplan–Meier analysis showed that both global and anterolateral scores were strong predictors of death (both p < 0.001). Multivariate Cox regression analysis showed that global lung ultrasound score was an independent predictor (hazard ratio, 1.08; 95% confidence interval, 1.01–1.16; p = 0.03) of death together with age, male sex, C-reactive protein, and creatine kinase-myocardial band.Conclusion: Lung ultrasound score as a semiquantitative tool can be easily measured by bedside lung ultrasound. It is a powerful predictor of in-hospital mortality and may play a crucial role in risk stratification of patients with COVID-19.

Background: Point-of-care lung ultrasound (LUS) score is a semiquantitative score of lung damage severity. High-resolution computed tomography (HRCT) is the gold standard method to evaluate the severity of lung involvement from the novel coronavirus disease (COVID-19). Few studies have investigated the clinical significance of LUS and HRCT scores in patients with COVID-19. Therefore, the aim of this study was to evaluate the prognostic yield of LUS and of HRCT in COVID-19 patients. Methods: We carried out a multicenter, retrospective study aimed at evaluating the prognostic yield of LUS and HRCT by exploring the survival curve of COVID-19 inpatients. LUS and chest CT scores were calculated retrospectively by 2 radiologists with >10 years of experience in chest imaging, and the decisions were reached in consensus. LUS score was calculated on the basis of the presence or not of pleural line abnormalities, B-lines, and lung consolidations. The total score (range 0–36) was obtained from the sum of the highest scores obtained in each region. CT score was calculated for each of the 5 lobes considering the anatomical extension according to the percentage parenchymal involvement. The resulting overall global semiquantitative CT score was the sum of each single lobar score and ranged from 0 (no involvement) to 25 (maximum involvement). Results: One hundred fifty-three COVID-19 inpatients (mean age 65 ± 15 years; 65% M), including 23 (15%) in-hospital deaths for any cause over a mean follow-up of 14 days were included. Mean LUS and CT scores were 19 ± 12 and 10 ± 7, respectively. A strong positive linear correlation between LUS and CT scores (Pearson correlation r = 0.754; R² = 0.568; p < 0.001) was observed. By ROC curve analysis, the optimal cut-point for mortality prediction was 20 for LUS score and 4.5 for chest CT score. According to Kaplan-Meier survival analysis, in-hospital mortality significantly increased among COVID-19 patients presenting with an LUS score ≥20 (log-rank 0.003; HR 9.87, 95% CI: 2.22–43.83) or a chest CT score ≥4.5 (HR 4.34, 95% CI: 0.97–19.41). At multivariate Cox regression analysis, LUS score was the sole independent predictor of in-hospital mortality yielding an adjusted HR of 7.42 (95% CI: 1.59–34.5). Conclusion: LUS score is useful to stratify the risk in COVID-19 patients, predicting those that are at high risk of mortality.

Association of Lung Ultrasound Score with Mortality and Severity of COVID-19: A Meta-Analysis and Trial Sequential Analysis

The aim – to determine the diagnostic value of lung ultrasound parameters in predicting outcomes of coronavirus disease 2019 (COVID-19) in oxygen-dependent patients requiring intensive care unit treatment. Materials and methods. We examined 105 patients with COVID-19 who needed supplemental oxygen and were treated in the Department of Anesthesiology and Intensive Care. The age of patients ranged between 39 and 80 years, 63 participants were male and 42 – female. To determine the diagnostic value of lung ultrasound parameters in predicting the severe course of COVID-19 in oxygen-dependent patients, they were divided into groups: Group I – recovered patients (n = 39); Group II – patients with a fatal outcome (n = 66). In all the patients, the diagnosis of COVID-19 was confirmed by RNA-SARS-CoV-2 detection in nasopharyngeal swab specimens. The patients were examined and treated according to the Protocol of the Ministry of Health of Ukraine. The lung ultrasound protocol used in the study included 14 lung examination zones and a score of lung tissue infiltration degree from 0 to 3 points. Statistical processing of the data was performed with Statistica for Windows 13 (StatSoft Inc., No. JPZ804I382130ARCN10-J). Results. In oxygen-dependent patients with severe COVID-19 and a fatal outcome, infiltrative changes in the lung parenchyma were more severe based on the lung ultrasound total score both at the time of admission (p &lt; 0.01) and after 5 days of treatment (p &lt; 0.01). The cutoff score of ≥19 at the time of hospitalization (AUC = 0.753, p &lt; 0.01; sensitivity – 76.9 %, specificity – 68.2 %) and ≥17 after 5 days of treatment (AUC = 0.799, p &lt; 0.01; sensitivity – 71.4 %, specificity – 92.1 %) had a prognostic value for assessing the risk of death in oxygen-dependent patients with severe COVID-19. A lung ultrasound score &gt;19 at the time of admission increased the risk of death by 2.96 times (RR = 2.96, 95 % CI 1.43–2.87, p &lt; 0.001). Lung ultrasound found pleural effusion only in oxygen-dependent COVID-19 patients who died. In the treatment dynamics after 5 days, the rate of pleural effusion detection in this group of patients was three times increased (from 9.1 % to 27.3 %, p &lt; 0.01). Conclusions. The study has revealed the diagnostic value of lung ultrasound parameters in predicting outcomes of COVID-19 in oxygen-dependent patients requiring intensive care unit treatment. Cutoffs of the total score characterizing the degree of lung tissue infiltration have been determined, that allowing to assert a high probability for a lethal outcome of the disease.

Patients with coronavirus disease 2019 (COVID-19) can develop severe bilateral pneumonia leading to respiratory failure. We aimed to study the potential role of lung ultrasound score (LUS) in subjects with COVID-19. We conducted an observational, prospective pilot study, including consecutive subjects admitted to an intermediate care unit due to COVID-19 pneumonia. LUS is a 12-zone examination method for lung parenchyma assessment. LUS was performed with a portable convex transducer, scores from 0 to 36 points. Clinical and demographic data were collected at LUS evaluation. Survival analysis was performed using a composite outcome including ICU admission or death. Subjects were followed for 30 d from LUS assessment. Of 36 subjects included, 69.4% were male, and mean age was 60.19 ± 12.75 y. A cutoff LUS ≥ 24 points showed 100% sensitivity, 69.2% specificity, and an area under the receiver operating characteristic curve of 0.85 for predicting worse prognosis. The composite outcome was present in 10 subjects (55.6%) with LUS ≥ 24 points, but not in the group with lower LUS scores (P < .001). Subjects with LUS ≥ 24 points had a higher risk of ICU admission or death (hazard ratio 9.97 [95% CI 2.75-36.14], P < .001). Significant correlations were observed between LUS and [Formula: see text], serum D-dimer, C-reactive protein, lactate dehydrogenase, and lymphocyte count. LUS ≥ 24 points can help identify patients with COVID-19 who are likely to require ICU admission or to die during follow-up. LUS also correlates significantly with clinical and laboratory markers of COVID-19 severity.

COVID-19 vasculitis and novel vasculitis mimics.

Decision letter: Metabolic biomarker profiling for identification of susceptibility to severe pneumonia and COVID-19 in the general population

Biomarkers of low-grade inflammation have been associated with susceptibility to a severe infectious disease course, even when measured prior to disease onset. We investigated whether metabolic biomarkers measured by nuclear magnetic resonance (NMR) spectroscopy could be associated with susceptibility to severe pneumonia (2507 hospitalised or fatal cases) and severe COVID-19 (652 hospitalised cases) in 105,146 generally healthy individuals from UK Biobank, with blood samples collected 2007–2010. The overall signature of metabolic biomarker associations was similar for the risk of severe pneumonia and severe COVID-19. A multi-biomarker score, comprised of 25 proteins, fatty acids, amino acids, and lipids, was associated equally strongly with enhanced susceptibility to severe COVID-19 (odds ratio 2.9 [95%CI 2.1–3.8] for highest vs lowest quintile) and severe pneumonia events occurring 7–11 years after blood sampling (2.6 [1.7–3.9]). However, the risk for severe pneumonia occurring during the first 2 years after blood sampling for people with elevated levels of the multi-biomarker score was over four times higher than for long-term risk (8.0 [4.1–15.6]). If these hypothesis generating findings on increased susceptibility to severe pneumonia during the first few years after blood sampling extend to severe COVID-19, metabolic biomarker profiling could potentially complement existing tools for identifying individuals at high risk. These results provide novel molecular understanding on how metabolic biomarkers reflect the susceptibility to severe COVID-19 and other infections in the general population.

Lung ultrasound (LUS) and chest computed tomography (chest CT) are largely employed to evaluate coronavirus disease 2019 (COVID-19) pneumonia. We investigated semi-quantitative LUS and CT scoring in hospitalized COVID-19 patients. LUS and chest CT were performed within 24 h upon admission. Both were analyzed according to semi-quantitative scoring systems. Subgroups were identified according to median LUS score. Patients within higher LUS score group were older (79 vs 60 years, p<0.001), had higher C-reactive protein (CRP) (7.2 mg/dl vs 1.3 mg/dl, p<0.001) and chest CT score (10 vs 4, p=0.027) as well as lower PaO2/FiO2 (286 vs 356, p=0.029) as compared to patients within lower scores. We found a significant correlation between scores (r=0.390, p=0.023). Both LUS and CT scores correlated directly with patients age (r=0.586, p<0.001 and r=0.399, p=0.021 respectively) and CRP (r=0.472, p=0.002 and r=0.518, p=0.002 respectively), inversely with PaO2/FiO2 (r=−0.485, p=0.003 and r=−0.440, p=0.017 respectively). LUS score only showed significant correlation with hs-troponin T, NT-pro-BNP, and creatinine (r=0.433, p=0.019; r=0.411, p=0.027, and r=0.497, p=0.001, respectively). Semi-quantitative bedside LUS is related to the severity of COVID-19 pneumonia similarly to chest CT. Correlation of LUS score with markers of cardiac and renal injury suggests that LUS might contribute to a more comprehensive evaluation of this heterogeneous population.

Decision letter: SARS-CoV-2 shedding dynamics across the respiratory tract, sex, and disease severity for adult and pediatric COVID-19

BackgroundBedside lung ultrasound (LUS) has emerged as a useful and non-invasive tool to detect lung involvement and monitor changes in patients with coronavirus disease 2019 (COVID-19). However, the clinical significance of the LUS score in patients with COVID-19 remains unknown. We aimed to investigate the prognostic value of the LUS score in patients with COVID-19.MethodThe LUS protocol consisted of 12 scanning zones and was performed in 280 consecutive patients with COVID-19. The LUS score based on B-lines, lung consolidation and pleural line abnormalities was evaluated.ResultsThe median time from admission to LUS examinations was 7 days (interquartile range [IQR] 3–10). Patients in the highest LUS score group were more likely to have a lower lymphocyte percentage (LYM%); higher levels of D-dimer, C-reactive protein, hypersensitive troponin I and creatine kinase muscle-brain; more invasive mechanical ventilation therapy; higher incidence of ARDS; and higher mortality than patients in the lowest LUS score group. After a median follow-up of 14 days [IQR, 10–20 days], 37 patients developed ARDS, and 13 died. Patients with adverse outcomes presented a higher rate of bilateral involvement; more involved zones and B-lines, pleural line abnormalities and consolidation; and a higher LUS score than event-free survivors. The Cox models adding the LUS score as a continuous variable (hazard ratio [HR]: 1.05, 95% confidence intervals [CI] 1.02 ~ 1.08; P < 0.001; Akaike information criterion [AIC] = 272; C-index = 0.903) or as a categorical variable (HR 10.76, 95% CI 2.75 ~ 42.05; P = 0.001; AIC = 272; C-index = 0.902) were found to predict poor outcomes more accurately than the basic model (AIC = 286; C-index = 0.866). An LUS score cut-off > 12 predicted adverse outcomes with a specificity and sensitivity of 90.5% and 91.9%, respectively.ConclusionsThe LUS score devised by our group performs well at predicting adverse outcomes in patients with COVID-19 and is important for risk stratification in COVID-19 patients.

Background: Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The primary diagnostic tool for pediatric COVID-19 patients is polymerase chain reaction (PCR). Chest imaging findings in pediatric COVID-19 cases are often normal or mild. The correlation of lung ultrasound (LUS) with chest computed tomography (CT) and chest X-ray (CXR) in pediatric COVID-19 patients has not been extensively studied. Objectives: This study aimed to assess the correlation of LUS with chest CT and CXR in detecting COVID-19 pneumonia in children. Methods: This single-center cross-sectional study included patients under 18 years of age diagnosed with COVID-19 by PCR or by abnormal chest CT findings suggestive of COVID-19, admitted to Mofid Pediatric Hospital between December 2021 and August 2022. All patients underwent LUS. Approximately half of the patients also had a chest CT, and CXR was performed on 35 patients. Lung ultrasound and CT scores were calculated, and the correlation between these scores was evaluated. The correlation between LUS and CXR was also analyzed. Results: Sixty patients were included, of whom 21 were female, with a mean age of 4.9 ± 4.0 years. A significant correlation was observed between LUS and CT scores (correlation coefficient = 0.467, P = 0.011). Lesion distribution was similar between LUS and CT. However, no significant correlation was found between LUS scores and CXR findings (P = 0.392). Sixteen out of 19 patients with normal CXRs had LUS scores ≤ 4. Notably, three patients with normal CXRs had LUS scores of 8, 14, and 14. Conclusions: Lung ultrasound was more sensitive than CXR and demonstrated a significant correlation with CT. Lung ultrasound may serve as a safe alternative to CT for detecting COVID-19 pneumonia in pediatric patients.

PurposeInformation regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome.MethodsBetween 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)—36 (worst) was assigned to each patient. LUS findings were compared with clinical data.ResultsThe median baseline total LUS score was 15, IQR [7–20]. Baseline LUS score was 0–18 in 80 (67%) patients, and 19–36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0–18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02–1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05–1.2], p = 0.0008.ConclusionHospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients’ management strategies, as well as resource allocation in case of surge capacity.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06212-1) contains supplementary material, which is available to authorized users.

PurposeThe aim of this study was to determine the effectiveness of two different lung ultrasonography (LUS) methods that can be used in the diagnosis of coronavirus disease 2019 (COVID-19) and to investigate their correlations with computed tomography (CT).MethodsIn this prospective, randomized, and single-blind study, 60 patients with COVID-19 were included. The patients were randomized to either the 12-zone LUS group (n=30) or the 14-zone LUS group (n=30). The correlation between LUS and thoracic CT scores was evaluated. As a secondary outcome measure, the characteristic features of the findings of thoracic CT and LUS were examined.ResultsThe study was completed with a total of 59 patients. Moderate and high correlations were found between the total CT and LUS scores in the 12-zone and 14-zone study groups. There were no statistically significant differences in the lesion types detected in patients using LUS and CT (P>0.05). The left lung lower lobe CT scores were statistically significantly lower in the 14-zone study group than in the 12-zone group (P=0.019). The left lower lobe CT and LUS scores were highly correlated in the 14-zone group (P<0.001, r=0.902).ConclusionThe results of our study indicated that the two different LUS examination methods performed in different patients had similar findings in terms of the diagnosis and their correlations with CT results.

Prevalence of obesity among adult inpatients with COVID-19 in France