COVID-19 POCUS – Day 15, Thoughts About The Pandemic

Point Of Care UltraSound & COVID-19

Daily thoughts & numbers on the COVID-19 pandemic from a M.D. working in the front lines at the Emergency Department in a hospital in Stockholm, Sweden.

Image: common findings in patients with COVID-19 pneumonia. Adapted from Peng et al 2020.

POCUS with focus on lung ultrasound is a great additional diagnostic tool for us at the ER and ED to help diagnose and monitor the development of our patients with COVID-19 pneumonia.

First, look at the pleural line, and do it systematically.

Image: one example of dividing the thorax into different zones for point of care lung examination with ultrasound. From Arbelot C et al 2020.

It doesn’t matter what numeric zone standard you use, what matters is that you are consistent and systematic.

Once you start looking at the lungs apically in a healthy lung you’ll see the following:

A - Lines - Normal Lung
Image: healthy lung.

The pleural line is visualized at top of the image as a thin & regular white line (no sign of inflammation/infection), there is movement/lung sliding (no sign of pneumothorax), and there is a-lines (the second horizontal white line below the the top one – a sign of a “dry” lung”).

In a COVID-19 pneumonia what you’ll (sometimes) get is the following pleural line:

Day 4

Image: day 4 after symptoms, in a patient developing a COVID-19 pneumonia.

The pleural line above is irregular, there is a bump in the pleura (sign of a infection/subpleural consolidation), and b-lines following that bump (the moving vertical line, sign of a “wet” lung).

Day 5
Image: day 5 after symptoms, in a patient developing a COVID-19 pneumonia.

Between the pleural line in the image to the left above and the thorax wall there is now fluid/edema shown as black (fluid becomes black with ultrasound). There are also several b-lines (signs of a “wet” lung, in other words: interstitial fluid) in each of the two captured images above, initially my experience is that these are seen more peripherally in some patients while they can maintain a-lines central/apical (COVID-19 seems, radiologically, to affect the lungs more peripheral/lower parts/subpleural *).

Pleural Findings in COVID-19
Image: pleural findings in a more advanced COVID-19 pneumonia.

Presumably a (radiologically) more severe pneumonia seen in the image above, with shredding (a highly irregular/inconsistent pleural line), several bumps indicative of infection/subpleural consolidation, and more prouncanced amount of fluid/edema between the pleural line and the thoracic wall.

Classic Findings in Pneumonia
Image: plural findings in a patient with bacterial pneumonia.

The patients with COVID-19 can also get a secondary bacterial infection as an addition to their COVID-19 pneumonia. In the image above signs of a larger subpleural irregularity is seen in the middle of the pleura line with consolidation (signs of a collapsed piece of lung) and within it: static air bronchograms (air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white), it is almost always caused by a pathologic airspace/alveolar process, in which something other than air fills the alveoli *). Keep in mind that static airbronchograms do not rule in bacterial pneumonia, they can also be a feature of just a COVID-19 pneumonia – a sign of resorptive atelectasis. You’ll need to look at the clinic and lab results for additional guidance as (almost) always with POCUS.

The COVID-19 pneumonia does not seem to produce large amounts of pleural effusion, however small amounts can be seen, sometimes also alongside with posterior/diafragmal/lower lung b-lines.

Sources:

[SWE] Powerpoint on COVID-19 & POCUS
The POCUS Atlas Images – COVID-19 Ultrasound Findings
[Study 2020] Lung Ultrasound in Emergency and Critically Ill Patients – Number of Supervised Exams to Reach Basic Competence
[STUDY 2020] Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic
Radiopaedia on COVID-19

COVID-19 Numbers Sweden 2020-04-08 *

687 deaths nationally
- 419 of them in Stockholm
8 419 confirmed cases nationally
DEATHS [SWE]

New confirmed deaths daily in Sweden.
(Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
ICU [SWE]

New Covid-19 patients Being Treated at the ICU in Sweden.
(Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
NEW CONFIRMED CASES [SWE]

New confirmed cases daily in Sweden.
(Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
TOTAL CONFIRMED CASES [SWE]

New confirmed cases accumulated over time in Sweden.
(Number of COVID-19 cases over time in Sweden, updates during mornings at 14:00 so todays numbers are not yet complete until the next day).
Intensive care Sweden: *
- 681 COVID-19 confirmed patients treated in the ICU in total so far
- 10,2 days from symptoms to ICU
- 24,4 % women
  
  Total number of recorded of COVID-19 patients needing ICU care each week. From Week 10 it seems to more than triple each week for the first 4 weeks. From week ten: 5 → 24 → 130 → 420 → 743 → (856 this week up until now, however since it’s only wednesday this weeks numbers are yet incomplete)