Tag Archives: COVID-19

COVID Life in the Prenatal Ultrasound Suite

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It is crazy to think that we are approaching the end of the second year of the worldwide COVID-19 pandemic. If the pandemic were a child, it would be walking, talking, and soon entering the “terrible twos”. In fact, my son was born in late February 2020, so all he knows is the pandemic. To him, masks are normal. He has even started to ask to wear a mask because that’s what everyone else does—mom, dad, his daycare teachers, his grandparents, his cousins. Though once he has one on, he quickly realizes that he prefers life without a mask.

Don’t we all, Andy?

As with most people, work life since the pandemic has changed. As a maternal-fetal medicine fellow, I’ve dedicated my training to the care of pregnant people and their fetuses, and I find the most fulfillment in the ultrasound suite. As cases rose, rooms filled with family and friends waiting for the words on the screen, “It’s a girl!”, during an anatomic survey became rooms with only a masked pregnant person and a masked sonographer (and the unmasked fetus, of course). While one adult support person has always been allowed to accompany each patient at our institution, they were frequently absent, whether they were working from home, caring for other children who are not allowed at appointments, or trying to limit exposures. Sonologists that previously were in and out of ultrasound rooms, scanning and counseling patients, were reading exams and counseling remotely.

Despite all the changes, the work continued. In fact, the pandemic has reminded us all that prenatal ultrasound is a medical necessity. At the height of the pandemic, elective medical procedures were canceled across the country. But the prenatal sonographers and maternal-fetal medicine specialists donned their N95s and face shields, and the prenatal ultrasound suite continued operation. In fact, cases that would have previously been managed with twice weekly non-stress tests were managed with weekly biophysical profiles instead to minimize potential exposures for a patient. Even with a current maternal diagnosis of COVID, arrangements were made to continue weekly umbilical artery Doppler studies for cases of fetal growth restriction. Some scans just cannot be delayed for 2 weeks. Despite all the changes, our purpose was clearer than ever—to provide excellent care for our patients, maternal and fetal.

With the widespread distribution of the vaccine and the decrease in cases, work life has settled into a “new normal”. Children have returned to in-person school, and the support person has returned to the ultrasound suite. N95s have been replaced by more comfortable surgical masks. Counseling a patient and their partner is no longer accompanied by the same degree of fear of a COVID exposure. But life is still far from my expectation of normal. The smiles after receiving the good news that there is one healthy intrauterine pregnancy with a strong heartbeat are still hidden behind cloth, as is the discomfort of an amniocentesis and the anguish when informed of a lethal fetal diagnosis. The impact that the mask continues to make on my ability to connect with and care for my patients cannot be understated.

As we head into the “terrible twos”, I know the pandemic will continue on and there will continue to be ups and downs. Misinformation regarding vaccination still limits widespread acceptance, but as research continues to demonstrate the safety and efficacy of vaccination, I still hold on to the hope that one day I will again be able to sit in a room with a patient unmasked and take in the unspoken communication I’ve so missed. But in the meantime, I’ll take the “new normal” and make the best of it for myself, my family, my colleagues, and my patients.

Kathy Bligard, MD, MA, FACOG, is a loving mom and third-year maternal-fetal medicine fellow at Washington University School of Medicine in St. Louis, MO.

Interested in learning more about patient care? Check out the following posts from the Scan:

Ultrasound Education in the Post-COVID Era

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In his book, The Innovator’s Dilemma, Clayton Christensen discusses the idea of disruptive technology. This market force that challenges industry norms can create new opportunities but also requires traditional market fixtures to adapt in order to maintain effectiveness.

Point-of-care Ultrasound (POCUS) has emerged as a disruptive technology in medical imaging. It relies heavily on education, both for new learners and also for those continuing to advance their knowledge base as skilled sonologists. As ultrasound technology improves and the scope of POCUS expands, two important facets of ultrasound education are collaboration and innovation. 

Ultrasound has traditionally been confined to specific rooms within the house of medicine. However, POCUS has grown to include a variety of specialties. Emergency medicine, critical care, hospital medicine, outpatient clinics, and even surgical specialties have all benefitted from “Ultrasound First” and the diagnostic specificity of ultrasound. But just as every disruptive technology creates challenges for traditional users, the democratization of ultrasound has required new users and traditional imaging specialties to rethink the imaging paradigm. 

Since each specialty (traditional or new adopter) comes to the table with a unique skillset and expertise, we benefit from collaboration. In the same way that a rising tide lifts all boats, cross-departmental collaboration allows for a broader understanding of the interplay between a patient’s anatomy, physiology, and ultrasound findings. 

In our institution, we have sought to use ultrasound as a tool to build bridges between departments. We have brought sonologists from various specialties together to teach anatomy with ultrasound. We have brought our ED residents to the MICU to scan patients with known pathology and MICU fellows to the ED. We have conducted cross-departmental ED/Radiology case conferences discussing the use of bedside ultrasound and traditional imaging. In each of these examples, we have sought ways to build collaborative relationships with other departments and benefit from each other’s particular perspective and experience. 

Ultrasound proficiency requires a firm foundation of both didactic knowledge and psychomotor skill. There is a significant interdependency between the classroom and the bedside. By restricting access to both spheres, COVID-19 has interrupted our normal way of living and educating and created a number of challenges to continuing ultrasound education. But, like a silver lining behind every dark cloud, the distance that COVID has created physically has drawn us together in unique ways. Distancing, occupancy limits, and virtual interactions have required us to reimagine ways of reaching learners. 

A large part of our continuing ultrasound education is a regular ultrasound lecture series. Virtual education has allowed for more flexibility with attendance. Individuals who traditionally could not attend an in-person lecture due to time or geographical constraints can now participate. We previously included learners from various departments within our institution. However, with virtual lectures, we have included students, residents, fellows, and faculty from other institutions throughout our greater region.

In addition to increasing the participant base, virtual education has allowed us to tap into a broader faculty base. The traditional model of medical education relies on in-person lectures and didactic education. Virtual education opens opportunities to include regional, national, and international experts. Prior to COVID, a visiting lecturer would have to take time away from their personal practice and travel to a particular place. Now, a speaker can attend via Zoom or other platforms. This has allowed us to invite outside experts to our educational forum. And for faculty looking to build an educational portfolio and progress through the academic ranks, virtual education allows for junior faculty to gain experience as visiting lecturers. 

As we emerge from the COVID era, I personally look forward to losing the masks, gathering together again, and seeing the word “virtual” used less ubiquitously in the English lexicon. But our imperative as ultrasound educators is to learn from the ways that COVID has changed our existing models for education and has caused us to adapt to new teaching methods. We should embrace the disruptive technologies of the past year and find ways to blend the advantages of cross-departmental, in-person learning with cross-institutional virtual education. To the extent that we are successful in this endeavor, we will find increased cohesion as a community, improved educational opportunities for our learners, and, ultimately, improved outcomes for our patients. 

Matthew Tabbut, MD, FACEP, is Director of Emergency Ultrasound at MetroHealth Medical Center in Cleveland, Ohio.

Interested in learning more about POCUS? Check out the following posts from the Scan:

Axillary and Neck Adenopathy in the Era of Mass COVID-19 Vaccination

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Can you please raise your arm? A few enlarged and unilateral axillary lymph nodes come into view. The cortex is eccentrically or diffusely thickened, they are enlarged, and they are hypervascular. Spotting an abnormal lymph node is not often the challenge, but knowing what to do with the lymph nodes can certainly be. First, I have a confession to make. I am a breast radiologist by training, and I am also fortunate to work in the body division in our department. This opportunity puts me in a unique position to explore both of the worlds and allows for collaboration and the exchange of knowledge.

Any radiologist who performs or interprets ultrasound exams knows that the patient history is of paramount importance along with available previous imaging exams. For example, a recently diagnosed breast cancer, unilateral cellulitis, and lymphoma all influence the management of axillary adenopathy. Similarly, cervical adenopathy can be seen as a reactive finding with head and neck infection, as well as in the setting of known malignancy like head/neck and thyroid cancers, which are prone to metastasize to neck lymph nodes. Vaccination history is also important when considering unexplained adenopathy, and it becomes particularly important with the introduction of the COVID-19 vaccines, which is a mass vaccination undertaking.

The COVID-19 vaccination is administered in the deltoid muscle. As a result, the reactive locoregional adenopathy in the axilla and cervical region has been observed (1). Axillary and/or cervical adenopathy as unsolicited adverse events for the Pfizer-BioNTech vaccine were reported in up to 0.3% among vaccine recipients (as opposed to 0.1% in the placebo group) (2). This adenopathy had onset about 2 to 4 days after vaccination and lasted an average of about 10 days. In the Moderna trial, 1.1% of the vaccination group versus 0.6% of the placebo group reported axillary and/or cervical adenopathy within 2 to 4 days after vaccination (3). However, the median duration of adenopathy with the Moderna vaccine was reported to be 1 to 2 days. It is important to note that these trials did not pursue the incidence of adenopathy via imaging such as ultrasound or regular physical examinations by a practicing physician after vaccination. Therefore, true incidence of axillary or cervical adenopathy remains unknown and is likely much higher than reported.

A total of 0.02% to 0.04% of otherwise normal screening mammograms present with unilateral adenopathy (4-6). During the early months of 2021, it was surprising to encounter a higher frequency of screening mammograms demonstrating unilateral adenopathy, which subsequently required a screening callback for further evaluation. As word spread in the breast imaging community, the Patient Care and Delivery Committee of the Society of Breast Imaging (SBI) issued a set of management guidelines in January 2021 for axillary adenopathy following the COVID-19 vaccination (7).

The dilemma of unilateral adenopathy extended beyond just screening mammograms. Any exams covering the anatomical regions of the axilla and lower neck started to show enlarged lymph nodes. Some examples of these exams include soft tissue ultrasound in the setting of a palpable mass, screening ultrasound exams for indications such as thyroid cancers, and cross-sectional examinations including MRI shoulder exams, CT Chest, and PET-CT.

Locoregional adenopathy has been encountered in the setting of other vaccines like influenza and shingles. However, unlike other vaccines with documented adenopathy among adults, the COVID-19 vaccine is a mass-scale vaccination program and the incidence of adenopathy is expected to be very high in numbers. Furthermore, the vaccination history is not routinely available in the medical chart, at least in early 2021, presumably due to a lack of automated connection between state health departments and unique health center-based electronic medical records. Therefore, effort should be made to document vaccination history either at the time of scheduling or at the time of imaging. At our Institution, the COVID-19 vaccine history including the timing of dose(s) is now routinely reviewed and documented for all breast exams including mammography (both screening and diagnostic), ultrasound, and MRI exams as well as ultrasound exams evaluating the axillary and/or neck regions.

Cancer screening is an important and challenging responsibility. Early detection is important in order to improve mortality and reduce morbidity. The COVID-19 vaccination campaign continues, and the race to protect as many people as possible is more important than ever. As radiologists, it is imperative to follow the data and carefully evolve in order to appropriately diagnose vaccine-related reactive adenopathy while avoiding the unintentional consequence of missing a cancer diagnosis.

A 64-year-old female patient with a history of adenoid cystic carcinoma of the right tongue with prior multiple recurrences and treatments, now presents with a mass along the left thyroidectomy bed. During the initial CT imaging, left thyroidectomy bed mass was confirmed and enlarged left axillary lymph nodes (a) were also noted (largest measuring 10 mm in short axis). This was followed by the PET-CT exam to identify additional sites of metastatic disease. PET-CT was performed about 2 weeks after the initial CT, and the CT component of PET-CT (b) shows decreased size of left axillary node, now measuring 7 mm in short axis. Axial fused PET-CT image (c) shows FDG-avidity of this lymph node, with SUV measurement of 5.56. Ultrasound image (d) shows a round node with no discernible fatty hilum. It was noted that the patient recently received a COVID-19 vaccine prior to the first CT exam. Since biopsy of the thyroidectomy bed mass showed metastasis, biopsy of left axillary node was also pursued, which revealed no evidence of metastatic disease. The left axillary node enlargement was thought to be secondary to recent COVID-19 vaccination. 

So, where do we go from here now that we know adenopathy has been reported with both the Moderna and Pfizer vaccines? Initial consensus statement from a multidisciplinary panel specifically highlights the benefit of prioritizing COVID vaccination among patients with known cancer history, as the protection offered by the vaccine outweighs the unintended side effect of adenopathy (1).

Here, we would like to discuss possible solutions highlighted by the Society of Breast Imaging (SBI) and multi-institutional cancer imaging specialists, along with solutions based on our anecdotal institutional experience, that might be of benefit when faced with the dilemma of adenopathy in your clinical practice following COVID-vaccination.

  • Collaborate with your colleagues in other divisions and departments. Coordinate and establish a consistent algorithm to assist with the management of unexpected adenopathy in the context of recent COVID-19 vaccination.
  • Document COVID-19 vaccination history. This could consist of three phases: 1) The collected information could possibly include date of vaccine doses, laterality of the arm receiving the vaccine, and the brand of the vaccine) prior to a screening exam, particularly when it involves a head/neck or axillary evaluation. 2) Once set up, this strategy of vaccination documentation could then be expanded to all modalities including cross-sectional imaging exams, either at the time of scheduling or at the time of patient’s intake on the day of the exam. 3) The final phase would consist of documentation across your entire hospital system at the time of scheduling of various appointments or using online secured tools to encourage patients to document the same on a voluntary basis. Inter-connection between different systems already existing on many Electronic Medical Record (EMR) systems would be a powerful tool in this regard. Organized COVID vaccination history in a standard location within the EMR could improve accessibility for all healthcare providers.
  • Consider the timing of a routine screening exam. If the screening exam is non-urgent, consider scheduling the exam at a minimum of 4–6 weeks following the second dose of the COVID vaccine (SBI). However, a longer interval of 6 weeks has also been advised in this setting given preliminary evidence of adenopathy persisting at 4 weeks (1). The patient’s existing risk factors and anxiety should also be considered while pursuing delaying the exam.
  • Keep your patients informed. Discuss the known reports of adenopathy following vaccination. Review short-term follow-up as a reasonable initial option in this situation and when biopsy may be indicated.
  • Know when tissue diagnosis may be indicated. According to SBI, in the absence of any other suspicious mammographic finding or contributing history beyond the vaccine, short-term follow-up in 4–12 weeks following the second vaccine dose can be considered. If axillary adenopathy persists after that period of time, tissue diagnosis is warranted to exclude breast and non-breast malignancy. However, for patients with a newly diagnosed breast cancer, it may be more appropriate to rule out metastasis with a biopsy instead of short-interval imaging follow-up.
  • Identify clearly abnormal lymph nodes. Reactive lymph nodes typically present as diffuse enlargement while maintaining their reniform shape. Fatty hilum is present, although could be thinned out. Ultrasound exams might show tiny hypoechoic (not anechoic) areas, indicative of prominent germinal centers. On PET-CT exams, the standardized uptake values (SUVs) of >7.0 have been reported within the lymph nodes as opposed to the typical scenario of reactive lymph nodes in the neck showing SUVs between 2 and 3. However, heterogeneous distribution of SUVs within lymph nodes, clearly necrotic or cystic areas within lymph nodes across all modalities, calcifications on CT and echogenic foci on ultrasound would indicate clearly abnormal lymph nodes, and tissue sampling in these cases will be indicated irrespective of COVID vaccine administration.  

It is important to keep in mind that new knowledge and data continue to contribute to evolving guidelines and that current recommendations may change as we learn more.

Dr. Noelle Hoven is an Assistant Professor in the breast imaging division and Dr. Anil Chauhan is an Associate Professor in the thoracoabdominal division in the diagnostic radiology department at the University of Minnesota.

References:

  1. Becker AS, Perez-Johnston R, Chikarmane SA, et. al. Multidisciplinary Recommendations Regarding Post-Vaccine Adenopathy and Radiologic Imaging: Radiology Scientific Expert Panel. [published online ahead of print February 24, 2021] Radiology. doi: 10.1148/radiol.2021210436.
  1. Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020; 383(27):2603–2615.
  1. Baden LR, El Sahly HM, Essink B, et al. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J Med. 2021; 384(5):403–416.
  1. Patel T, Given-Wilson RM, Thomas V. The clinical importance of axillary lymphadenopathy detected on screening mammography: revisited. Clin Radiol. 2005; 60:64–71.
  1. Lim ET, O’Doherty A, Hill AD, Quinn CM. Pathological axillary lymph nodes detected at mammographic screening. Clin Radiol. 2004; 59:86–91.
  1. Chetlen A, Nicholson B, Patrie JT, Harvey JA. Is screening detected bilateral axillary adenopathy on mammography clinically significant? Breast J. 2012; 18:582–587.
  1. SBI Recommendations for the Management of Axillary Adenopathy in Patients with Recent COVID-19 Vaccination. Society of Breast Imaging Patient Care and Delivery Committee. https://www.sbi-online.org/Portals/0/Position%20Statements/2021/SBI-recommendations-for-managing-axillary-adenopathy-post-COVID-vaccination.pdf

Interested in learning more about ultrasound and COVID-19? Check out the following posts from the Scan:

Sink or Swim? Modifying POCUS Medical Education Curriculum During the Coronavirus Pandemic

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Modifying a point-of-care ultrasound (POCUS) medical education curriculum initially designed for 4-year matriculation into a 3-year experience is undoubtedly challenging. This 1-year shortening, combined with the added constraints of mandated social distancing guidelines of the coronavirus pandemic, caused us to search for concrete answers to these new directives that would lead us to either sink or swim in this new ocean of learning.

Claude Bernard, a 19th-century French physiologist, remarked that “it is what we think we know already that often prevents us from learning.” This educational concept was true with our efforts to modify a successful ultrasound in medical education curriculum and transform it into a case-based learning approach for a condensed 18-month pre-clerkship ultrasound curriculum.

How we had conducted ultrasound labs previously would have to be revisited, revised, and revamped to transform the curriculum successfully.

Planning began to modify the ultrasound curriculum for the 18-month pre-clerkship experience approximately 2 years before the pandemic was even on the horizon. In-person meetings were held with fellow faculty to discuss and debate the patient-centered learning course’s mission and goals and where the ultrasound curriculum would be housed. Our discussions took place with ease, and ideas for collaboration easily flowed. Plans were made for in-person, hands-on scanning where students scanned each other, volunteers, or standardized patients, without giving any thought to the physical contact.

There was no thought to the exam rooms’ square footage or how students would enter and exit the ultrasound center. Live introductory lectures at the onset of each lab were planned for 25–30 students to introduce the case and review the scanning techniques and logistics for each lab session. The planning included no discussion of online learning or simulated scanning for students from a remote location. Ultrasound instruction would proceed into the new curriculum with a slight modification to how ultrasound content had been previously delivered.

Then, while finalizing our plans for a start date of August 2020, all in-person instruction was suspended for our institution. It was mid-March, and we had a nearly solidified sketch of the ultrasound lab logistics and learning methods for the inaugural class of the 3-year medical school and the 18-month pre-clerkship curriculum.

Nevertheless, that suddenly changed, and the uncertainty of instructing anyone in-person to do any part of the curriculum was up for discussion. The faculty was mandated to work from home away from the ultrasound center with its hand-held systems, full-size ultrasound machines, and simulation capabilities. Student interactions were reduced to phone calls, emails, and video interactions within online course offerings as each student cohort was scattered throughout the 159 counties of our state.

Learning to conduct curriculum meetings through online platforms filled our days. Trying to accomplish fully online ultrasound electives with a plethora of students and revamp the new ultrasound curriculum within the changing coronavirus guidelines stayed on our minds as we struggled through the spring and early summer.

Nevertheless, we made it!

When the inaugural class of the new pre-clerkship curriculum began, we laid out a plan to keep students, staff, and faculty safe through the 3W’s: wearing a mask, watching physical distance, and hand washing.

Facilities management personnel had surveyed our ultrasound exam rooms and learning spaces and posted how many students could be in each room. Hand sanitation stations and masks were made available for students as they entered the ultrasound center. Signage and arrows were erected to direct students in and out of the ultrasound center in a one-way fashion. An online meeting platform was set up in each exam room for students to hear live instruction before beginning the lab. Instructors utilized a laser point at each room’s door to direct student scanning and maintain social distancing. Students used hand-held ultrasound equipment with image transfer capabilities to obtain images needed to complete their online case-based ultrasound assignments. Although these safety measures were not visualized in our early curriculum planning meetings, the ultrasound curriculum was successfully delivered!

While we did not meet the goal of remote hands-on ultrasound instruction for all ultrasound labs during the pandemic, we learned to conduct in-person ultrasound scanning labs safely and effectively within a new accelerated medical school curriculum. The constraints and trials of a global pandemic did not preclude us from putting aside what we already knew and navigating a new course into the future!

Headshot photograph of the post author, Rebecca J. Etheridge. She is shown in front of a gray background wearing a blue suit jacket and has shoulder-length red-brown hair.

Rebecca J. Etheridge, EdD, RDMS, is an assistant professor at the Medical College of Georgia at Augusta University.

Interested in learning more about ultrasound education? Check out the following posts from the Scan:

POCUS in COVID-19—Clutch or Not So Much?

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Health care workers see patients with undifferentiated symptoms day and night in emergency departments, hospitals, and outpatient clinics, so we are hard-pressed to identify symptoms that are NOT part of the constellation of symptoms seen with COVID-19. Practically speaking, any patient we encounter is likely to have one or more of the symptoms, which include incredibly common findings such as fever, chills, cough, shortness of breath, chest pain, headache, myalgias, nausea, vomiting, diarrhea, abdominal pain, and rash!

A Critical Question Exists: How Might Point-of-Care Ultrasound (POCUS) Be Best Utilized in This Pandemic?

While data is still being collected and definite answers may not be attainable, we seek to outline a few scenarios where POCUS may greatly aid every-day patient care.

No Test or Slow Test Scenario

While COVID-19 testing is more available than early in the pandemic, there are still communities in the U.S. and worldwide that lack access to testing or expeditious results. A prior post on AIUM’s The Scan, “My Sonography Experience With COVID-19”, (https://aiumthescan.blog/2020/04/21/my-sonography-experience-with-covid-19/) by Yale Tung Chen, MD, PhD, details common POCUS findings that may aid in diagnosing COVID-19 when tests or test results are not available.1

POCUS offers greater sensitivity for COVID-19 pneumonia than CXR and is safer (no ionizing radiation) and more cost-effective in comparison to CT imaging of the chest.2

Is This Patient’s Shortness of Breath Due to COVID-19 Pneumonia?

The differential diagnosis of a patient with undifferentiated shortness of breath can be broad. It includes not just COVID-19 pneumonia, but also pulmonary embolism, heart failure, pericarditis, pericardial effusion/tamponade, pneumothorax, and many more.

POCUS can reliably exclude decreased left ventricular ejection fraction, pericardial effusion, and pneumothorax, often rapidly shortening the differential. And POCUS findings of right heart strain may help direct clinicians toward further testing for pulmonary embolism (PE) or the use of thrombolytics in patients in extremis. Detection of a deep venous thrombosis (DVT) may serve as a proxy for diagnosing PE in a patient with shortness of breath or chest pain with a high probability of PE.

As has long been recognized but is reinforced in the COVID-19 pandemic, the ability to detect these pathologies at the bedside makes POCUS an invaluable tool for patients who are too critically ill to be transported for further diagnostic studies.

POCUS Takes One for the Team, Limiting Healthcare Worker Exposure

Limiting the number of people involved in the hands-on care of a patient with COVID-19 is an important principle in reducing healthcare worker (HCW) exposure.

In another previous post on The Scan, “How the COVID-19 Pandemic Has Changed Your Practice”, Margarita V. Revzin, MD, MS, detailed the time-intensive protocols that are in place to protect both the patients receiving and the HCWs performing ultrasound exams in the radiology department (https://aiumthescan.blog/2020/12/15/how-the-covid-19-pandemic-has-changed-your-practice/).

The ability of POCUS to answer binary clinical questions may help limit the exposure of HCWs who are not part of the primary team for the infected patients. In POCUS, the ultrasound exam is performed by a provider responsible for the comprehensive care of the patient—in essence, one of the HCWs who is primarily caring for the patient. When POCUS is able to definitively answer the clinical question at the bedside, additional imaging studies may be unnecessary, thus reducing the number of consulting providers exposed to a patient with COVID-19.

POCUS as the Great Prognosticator

The lung ultrasound findings of COVID-19 pneumonia precede findings on physical exam and x-ray imaging. Therefore, ultrasound could be used as a screening tool and additional data point in triaging patients and determining if they can be treated as an outpatient or admitted to the hospital.

Studies have suggested that infero-posterior lung POCUS findings are most sensitive for the diagnosis of COVID-19 pneumonia but that anterior lung findings best predict the need for non-invasive ventilation support while hospitalized.3

In addition, calculation of a lung ultrasound score (LUS) may help quantify severity of disease, with higher LUS predicting invasive ventilatory support need, ARDS, and death.4

The Future

POCUS is unique. It is the imaging modality that most easily incorporates into telehealth via remote guidance. As the role of POCUS in diagnosis, monitoring, and prognostication in pulmonary disease is better defined, it may play a role in determining care plans for patients seeking care via telehealth while minimizing COVID-19 exposure for both HCWs and patients.5,6

Furthermore, combining handheld ultrasound devices with novel artificial intelligence algorithms may allow for the automation of diagnosis and monitoring as described in a prior blog post by Alper Yilmaz, PhD, “Using AI and Ultrasound to Diagnose COVID-19 Faster” (https://aiumthescan.blog/2020/08/11/using-ai-and-ultrasound-to-diagnose-covid-19-faster/).

References

  1. Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for patients with COVID-19: a simple, quantitative, reproducible method. J Ultrasound Med. 2020 Jul;39(7):1413-1419. doi: 10.1002/jum.15285. Epub 2020 Apr 13. PMID: 32227492; PMCID: PMC7228287.
  2. Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 May;46(5):849-850. doi: 10.1007/s00134-020-05996-6. Epub 2020 Mar 12. PMID: 32166346; PMCID: PMC7080149.
  3. Castelao J, Graziani D, Soriano JB, Izquierdo JL. Findings and prognostic value of lung ultrasound in COVID-19 pneumonia. J Ultrasound Med. 2020 Sep 16. doi: 10.1002/jum.15508. Epub ahead of print. PMID: 32936491.
  4. Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care. 2020 Dec 22;24(1):700. doi: 10.1186/s13054-020-03416-1. PMID: 33353548; PMCID: PMC7754180.
  5. Kirkpatrick AW, McKee JL, Volpicelli G, Ma IWY. The potential for remotely mentored patient-performed home self-monitoring for new onset alveolar-interstitial lung disease. Telemed J E Health. 2020 Oct;26(10):1304-1307. doi: 10.1089/tmj.2020.0078. Epub 2020 Jul 10. PMID: 32654656.
  6. Kirkpatrick AW, McKee JL. Re: “Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method”-Could Telementoring of Lung Ultrasound Reduce Health Care Provider Risks, Especially for Paucisymptomatic Home-Isolating Patients? J Ultrasound Med. 2021 Jan;40(1):211-212. doi: 10.1002/jum.15390. Epub 2020 Jul 8. PMID: 32639037; PMCID: PMC7362148.

Jennifer Carnell, Tobias Kummer, and Arun Nagdev are the leaders (2020–2022) of the AIUM Point-of-Care Ultrasound Community. Jennifer Carnell is the Secretary, Tobias Kummer is the Vice-Chair, and Arun Nagdev Arun is the Chair.

Interested in learning more about POCUS? Check out the following posts from the Scan:

How the COVID-19 Pandemic Has Changed Your Practice

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Coronavirus disease 2019 (COVID-19, also known as SARS-CoV-2) was declared an official pandemic by the World Health Organization (WHO) on March 11, 2020, with infections reported in all countries around the world. As of today, November 12, 2020, there have been almost 53 million cases of COVID-19 reported worldwide, with over 1.3 million COVID-19-associated deaths.

This pandemic is severe, and the mortality and morbidity associated with this disease cannot be overstated. Although most infected patients are either asymptomatic or experience mild symptoms, a significant number end up in serious or critical condition. This is the patient population that develops a number of complications that affect all body systems, and this group of patients should be very closely monitored in the hospital setting.

Radiology professionals play a significant role in the diagnosis of infected individuals, identification of complications that are not apparent on physical exam or laboratory analysis, and the follow-up imaging assessment of known COVID-related complications. Given that this virus is highly contagious, it became very apparent that safe methods for patient assessment had to be designed and implemented. Ultrasound serves as a first-line imaging modality for evaluation of a number of COVID-19 pathologies and related complications, including evaluation of pulmonary, hepatobiliary, renal, gastrointestinal, and cardiac manifestations. It is the modality of choice in the pediatric population and in pregnant patients. Moreover, ultrasound plays a critical role in the evaluation of patency of peripheral and central vascular systems, including both the arterial and venous circulation as well as solid organ perfusion.

Due to the highly contagious nature of COVID-19, our routine ultrasound radiology practice had to undergo dramatic changes in order to ensure proper infection prevention. We accomplished this through the establishment of control measures and good hygiene practices that were shown to limit spread of COVID‐19 and protect patients, sonographers, and physicians. In addition to following specific guidelines (established at the beginning of the pandemic by the ACR and the SRU) for cleaning and disinfection of ultrasound equipment and use of personal protective equipment (PPE), we also incorporated our own changes that we found to be beneficial in preventing spread of the infection and limiting staff exposure. 

At our institution, all patients are considered to be SARS-CoV-2 persons under investigation (PUI), including those without respiratory or digestive symptoms, and appropriate safeguards are taken while performing examinations.

Given the fact that transmission of SARS-CoV-2 occurs primarily through respiratory droplets, fomites, and possibly aerosols, we emphasize the use of portable ultrasound imaging at the patient’s bedside whenever feasible, with the radiology staff wearing appropriate PPE, including an N95 mask, gloves, protective eyewear or an overlying face shield, and a disposable gown.We request that all patients wear surgical masks during the examination.    

Equipment must be disinfected after every exposure to COVID-19 positive or suspected positive patients. According to the Centers for Disease Control and Prevention (CDC), surfaces need to be either washed with soap and water or decontaminated using a low-level or intermediate-level disinfectant such as iodophor germicidal detergent solution, ethyl alcohol, or isopropyl alcohol. Vendors should be contacted to determine the safest disinfectant for each piece of equipment. Radiology technologists should perform sanitizing procedures while remaining in full PPE.    

It is uncertain how long the air within an examination room remains infectious. Contributing factors likely include the size of the room, the number of air exchanges per hour, the length of time the patient was in the room, type of filters installed in the room, and whether an aerosol-generating procedure was performed. Use of air exchange measures vary depending on the availability of equipment. At our institutions, a 20-minute downtime is mandated for disinfection of the air in an examination room.

The keyboard and monitor of the ultrasound equipment are covered with a plastic drape or cover, and only the required probes are utilized during specific examinations. External transducers require low-level disinfection between procedures, while internal transducers require a single-use transducer cover and high-level disinfection between patients. It should be noted that products that are alcohol-based should be avoided when cleaning keyboards and track balls. If possible, a dedicated machine should be utilized for COVID-positive or suspected-positive patients. The machine should be cleaned with an EPA-approved disinfectant for viral pathogens, by a technologist in full PPE.

One of the primary changes that we implemented within our ultrasound division is the utilization of abbreviated protocols while imaging COVID-19 patients. We found that abbreviated protocols are useful and sufficient for the diagnosis of most COVID-19-related pathologies and complications, and are usually able to provide answers to the questions posed by referring clinicians. We strongly believe that abbreviated protocols have allowed us to decrease technologists’ exposure to the infection and the amount of time spent during imaging exams. When performing ultrasound examinations, we focus only on the area of interest and acquire cine clips rather than still images during the exam. It has also been shown that post processing of images, including image labeling and parameter optimization, significantly decrease the amount of time spent on scanning.

Lastly, it is important to recognize that not every patient benefits from imaging. We carefully review requests for imaging studies with the patient providers and try to weigh the benefits of imaging against the risk of exposure. The guiding principle to keep in mind is that studies don’t need to be performed unless patient management is going to be affected by the imaging findings. 

The ultrasound workforce provides a valuable clinical service but is particularly vulnerable because of the prolonged close physical contact between staff and patients. Hopefully, this blog post will serve as a resource to help practitioners improve safety and minimize exposure risk during the performance of ultrasound examinations.

From top left: Basilic vein thrombosis, chest wall hematoma, gallbladder sludge, internal jugular vein occlusion, lung consolidation with air bronchograms, lung interstitial edema with B lines, popliteal artery occlusion, and urinary bladder clot.
Lung US annotated B lines and pleural thickening.

For additional reference:

  1. Revzin MV, Raza S, Warshawsky R, D’Agostino C, Srivastava NC, Bader AS, Malhotra A, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 1: Viral Pathogenesis and Pulmonary and Vascular System Complications”. RadioGraphics 2020 Oct;40(6):1574–1599. doi: 10.1148/rg.2020200149 Monograph Issue.
  2. Revzin MV, Raza S, Srivastava NC, Warshawsky R, D’Agostino C, Malhotra A, Bader AS, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations.” Radiographics 2020 Nov–Dec;40(7):1866–1892. doi: 10.1148/rg.2020200195.

Margarita V. Revzin, MD, MS, FSRU, FAIUM, is an Associate Professor of Diagnostic Radiology in the Department of Radiology and Biomedical Imaging at Yale University School of Medicine, in New Haven, Connecticut.

Interested in learning more about ultrasound and COVID-19? Check out the following posts from the Scan:

Point-of-Care Ultrasound for Pregnant Patients?

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Point-of-care ultrasound, or POCUS, has become fully incorporated into almost every aspect of clinical care over the past 5 years. COVID-19 has further solidified the use of POCUS for the evaluation of dyspnea and cough given its portability. But what about the use of POCUS for a woman during pregnancy?

Ultrasound has been consistently employed to evaluate the fetus in all 3 trimesters. There is another patient, though; the mother! Rising maternal morbidity and mortality secondary to cardiovascular disease requires the obstetrical care provider to employ point-of-care clinical assessment that targets the maternal cardiovascular system.  This is the problem and the solution may be “getting a CLUE” by implementing cardiac limited ultrasound evaluation (CLUE) at the bedside as suggested by Kimura et al.

In contrast to fetal imaging, which utilizes higher frequency transabdominal and transvaginal ultrasound probes, penetration of the chest wall requires a lower frequency probe (2–4 mHz). Ideally, a low frequency probe that is compatible with most commonly used obstetrical equipment would facilitate ease of utilization. The CLUE protocol employs the following views: parasternal long axis view, lung anteroapex view, lung posterolateral base view, subcostal view, and right sub-xyphoid view. These views allow the clinician to evaluate the patient for pathophysiologic findings including the presence of pleural or pericardial effusion; abnormal contractility, chamber enlargement, and valvular dysfunction. Assessment of the size and collapsibility of the inferior vena cava can be a noninvasive marker of right-sided filling pressures to evaluate volume status in an oliguric patient with preeclampsia.

I propose that CLUE be extrapolated from the non-pregnant patient population for applicability in the pregnant patient population. This may be particularly relevant in certain scenarios including: triage of pregnant women with cardiac symptoms in an outpatient or in-patient setting as an adjunct to the physical exam; and labor and delivery units with lack, or limited immediate availability, of formal echocardiography. While anecdotal case experience suggest utility, formal studies designed to compare CLUE in pregnancy to the gold standard of transthoracic echocardiography will confirm the feasibility of CLUE in this unique population. Even though obstetricians are trained to perform obstetrical and gynecologic ultrasound, and are well versed with the existing ultrasound equipment on their units, additional training may be required. In addition to obstetrical care providers, other clinicians, such as emergency room and internal medicine providers, may also perform CLUE to assess the maternal cardiopulmonary system.

Limitations of point-of-care cardiac examination of the heart include both patient characteristics and technique. Large body mass size and enlarged breast tissue common in pregnancy can lead to imaging acquisition challenges. Off-axis imaging technique can lead to false positive or false negative diagnoses. Patient positioning should be optimized and shifted to left lateral tilt to accommodate aortocaval compression.

CLUE demonstrates potential as an innovative diagnostic point-of-care technique that can be adapted to maternal use. Timely future clinical studies that compare CLUE with formal echocardiography during pregnancy will further clarify its feasibility and full utility in the clinical arena as a tool to combat rising maternal morbidity in the new millennium.

  1. Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. J Ultrasound Med. 2015;34:1683–1690.

Carolyn M. Zelop, MD, is a Director of Perinatal Ultrasound and Research at The Valley Hospital, Ridgewood, New Jersey; a Clinical Professor of Ob/ Gyn at NYU School of Medicine; and she is a senior member of the AIUM and the ACOG rep to women’s imaging for ACR.

Interested in learning more about ultrasound and pregnancy? Check out the following posts from the Scan:

Using AI and Ultrasound to Diagnose COVID-19 Faster

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Coronavirus disease 2019 (COVID-19) is a newly identified virus that has caused a recent outbreak of respiratory illnesses starting from an isolated event to a global pandemic. As of July 2020, there are over 2.8 million confirmed COVID-19 cases in the U.S. and over 11.4 million worldwide. In the United States alone, over 130,000 Americans have died from COVID-19, with no end in sight. A major cause of this rapid and seemingly endless expansion can be traced back to the inefficiency and shortage of testing kits that offer accurate results in a timely manner. The lack of optimized tools necessary for rapid mass testing produces a ripple effect that includes the health of your loved ones, jobs, education, and on the national level, a country’s Gross Domestic Product (GDP), but artificial intelligence and ultrasound may help.

STATE OF ART IN DIAGNOSIS

Prof. Alper Yilmaz, PhDCurrently, there are two types of tests that are conducted by healthcare professionals–diagnostic tests and antibody tests. The diagnostic test, as the name implies, helps diagnose an active coronavirus infection in a patient. The ideal diagnostic test and the “gold standard” according to the United States Center for Disease Control (CDC) is the Reverse Transcription Polymerase Chain Reaction, or simply, RT-PCR. RT-PCR is a molecular test not only capable of diagnosing an active coronavirus infection, but it can also indicate whether the patient has ever had COVID-19 or were infected with the coronavirus in the past. However, the time required to conduct the test limits its effectiveness when mass deployed.

A much faster but less reliable diagnostic test alternative to RT-PCR is an antigen test. Much like the gold standard, the antigen test is capable of detecting an active coronavirus infection in a much shorter timeframe. Although antigen tests produce rapid results, usually in about an hour, the results are deemed highly unreliable, especially with patients who were tested negative according to the US FDA.

In contrast, the antibody test is designed to search for antibodies produced by the immune system of a patient in response to the virus and is limited by its ability to only detect past infections, which is less than ideal to prevent an ongoing pandemic.

THE PROBLEM 

To combat the rapid expansion of an airborne virus such as COVID-19, or future variations of a similar virus, rapid and reliable solutions must be developed that aim at improving the limitations of current methods. Although highly accurate, methods such as RT-PCR do not meet the speed requirements needed for testing on a large scale. Depending on the location, diagnosis of an active coronavirus infection with RT-PCR may take anywhere between several hours and up to a week. When the number of daily human-to-human interactions are considered, the lack of speed in diagnosing an active coronavirus patient could be the difference between a pandemic or an isolated local event.

As an alternative to molecular tests, Computed Tomography (CT) scans of a patient’s chest have shown promising results in detecting an infection. However, in addition to not being recommended by the CDC to diagnose COVID-19 patients, there are many unwanted consequences with the use of CT scans. With CT scans used to diagnose multiple illnesses, some of which relate to serious emergencies such as brain hemorrhaging, they cannot be used as the primary tool for diagnosing COVID-19. This is especially true in rural areas where the healthcare infrastructure is underfunded. Mainly due to the required deep cleaning of the machine and room after each patient, which usually requires 60 to 120 minutes, many institutions are unable to provide CT scans as a viable primary diagnostic tool. Ultimately, given the need for CT scanners for several other health complications combined with limited patient capacity at each hospital, alternative methods must be developed to diagnose an active coronavirus patient.

THE SOLUTION 

Recently Point-of-Care (POC) devices have started to be adopted by many healthcare professionals due to its reliability and portability. An emerging popular technique, which adopts improvements made in mobile ultrasound technology, allows for healthcare professionals to conduct rapid screenings on a large scale.

Working since mid-March, when early cases of physicians adopting mobile ultrasound technology emerged, the research team at The Ohio State University, Dr. Alper Yilmaz and PhD student Shehan Perera, started developing a solution that can automate an already well-established process. Dr. Yilmaz is the director of the Photogrammetric Computer Vision lab at Ohio State. Dr. Yilmaz’s expertise in machine learning, artificial intelligence, and computer vision combined with the research experience of Shehan Perera laid a strong foundation to tackle the problem at hand. As it stands, the screening of a new patient, with the use of a mobile ultrasound device takes about 13 minutes, with the caveat that it requires a highly trained professional to interpret the results generated by the device. With the combination of deep learning and computer vision, the research team was able to use data generated from the ultrasound device to accurately identify COVID-19 cases. The current network architecture, which is the product of many iterations, is capable of detecting the presence of the virus in a patient with a high level of accuracy.

Many fields have been revolutionized with modern deep learning and computer vision technologies. With the methods developed by the research team, this technology can now allow any untrained worker to use a handheld ultrasound device, and still be able to provide a service that rivals that of a highly trained doctor. In addition to being extremely accurate, the automated detection and diagnosis process takes less than 10 minutes, which includes scanning time, and sanitation is as simple as removing a plastic seal that covers the device. The benefits of this technology can not only be useful for countries such as the United States, with a well-established healthcare system, but, more importantly, can significantly help countries and areas where medical expertise is rare.

CONCLUSION 

The United States healthcare system is among the best in the world, yet we are failing to provide the necessary treatment patients clearly need. The developments made in artificial intelligence, deep learning, and computer vision offer proven benefits, which can not only be leveraged to improve the current state of the global pandemic but can lay the foundation to prevent the next. Alternative testing methods such as mobile ultrasound devices combined with novel artificial intelligence algorithms that allow for mass production, distribution, and testing could be the innovation that could help decelerate the spread of the virus, reducing the strain on the global healthcare infrastructure.

Feel Free to Reach the Authors at: 

Photogrammetric Computer Vision Lab – https://pcvlab.engineering.osu.edu/
Dr. Alper Yilmaz, PhD
Email: Yilmaz.15@osu.du
LinkedIn: https://www.linkedin.com/in/alper-yilmaz

Shehan Perera
Email: Perera.27@osu.edu
LinkedIn: https://www.linkedin.com/in/shehanp/

References 

https://www.fda.gov/consumers/consumer-updates/coronavirus-testing-basics

https://www.whitehouse.gov/articles/depth-look-COVID-19s-early-effects-consumer-spending-gdp/#:~:text=BEA%20estimates%20that%20real%20GDP,first%20decline%20in%20six%20years.&text=This%20drop%20in%20GDP%20serves,in%20response%20to%20COVID%2D19.

 

Interested in learning more about COVID-19 or AI? Check out the following posts from the Scan:

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The Invisible Front Line

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2020’s trials seem to have come on like a freight train; full steam ahead with no signs of stopping. Australia was still burning when we first heard stories of a novel virus with pandemic potential in Wuhan, China. Numbers and other details seemed to change daily. Weeks went by as we watched world news intently, taking note of the infection rate and death toll, all the while steeling ourselves for a possible outbreak at home. As much as we tried to go about our daily lives, Wuhan and the virus was never too far from our minds. Was this virus airborne? There were still so many unanswered questions, but one thing was certain; COVID-19 was spreading like wildfire and it was only a matter of time now before we would be on our own front line.Huang

Sonographers and other medical professionals soon began deployment into COVID wards in our own hospitals: areas that had been sealed off and outfitted as negative pressure cohort units to treat the infected patients. Then the deluge of daily updates and dizzying policy changes began as we tried to keep up with CDC guidelines. Rumors surfaced of limited PPE (personal protective equipment) supplies. Only doctors and nurses needed n95s? Regular procedure masks were fine for everyone else? Surely that was incorrect. Surely they knew what kind of prolonged contact sonographers have with our patients? X-ray was making contact with every patient under investigation (PUI). CT was scanning countless chests. Worries intensified as we all tried to navigate this new reality.

I’ll never forget my first assignment in the cohort. Only one other sonographer in my department had gone into the cohort at that time. He relayed seeing 3 morgue carts lining a hallway on his first trip inside. I thought about that often in the days that followed and I knew my turn was coming. How would I handle that? Some of our respiratory therapy (RT) and interventional radiology (IR) colleagues had tested positive by this time. I thought about my little boy. I saw news coverage of doctors and nurses who were self-quarantining after their shifts to decrease the potential spread to their families. I didn’t have that option as a single mother.

Finally, it came: my first COVID+ request. I told myself it would be fine. I just needed to be brave, be safe, and stay alert. I’ve never been to battle but having the media images in my mind and knowing the death toll numbers, I imagined this is what it might feel like on some small level. I thought about the PPE shortage and the rumors that we wouldn’t have access to n95s. I steeled my nerves and walked one foot in front of the other with Apollo (my LOGIQ E10). I arrived outside the cohort and was immediately greeted by the plastic sheeting that sealed off the unit. I found an anteroom with shelves overflowing with supplies. A lovely volunteer helped outfit me with everything I needed: a fresh n95, a surgical mask to go on top, a contact gown, shoe covers, eye protection, and a scrub hat. We exchanged nervous chatter for a moment as she gave me a once over to make sure I was ready. She opened the door and I exhaled as I walked inside.

As I made my way to my first patient, I noticed things were definitely different. Physicians and nurses donned full respirator masks, patient information was written on the room windows so staff could see information such as code status from the hallway, and iv poles with extra tubing sat outside of patient rooms so nurses could adjust pumps without going inside. I also learned that doctors were either doing virtual or modified rounds with one MD per team going into the patient’s room while the rest stayed outside. One came in during my 30-minute exam. As I stood hip-to-hip with my patient, he stood at the foot of the bed, asked the patient a few questions, and was gone in about 2 minutes. It struck me how much extra caution was being taken for doctors and nurses to limit their exposure times.

Some other things in the cohort looked like business as usual. I saw radiographers and cardiac sonographers going about their usual work. I saw food service delivering meals. I saw housekeeping working to stay on top of the mountains of doffed contact gowns and other garbage. Everyone was working individually on this front line for a common goal: our patients. Yet, as I arrived home that day and turned on the news, I was once again told by the media that nurses and doctors are the essential workers in this pandemic. While I absolutely believe nurses and doctors deserve every ounce of recognition they receive, I sometimes think people forget that it takes a team to deliver excellent patient care. I was fortunate enough to be able to share my experiences with Alison Bowen of the Chicago Tribune recently in the hopes of illuminating just some of what we do in a day as Diagnostic Medical Sonographers.

My first patient had a seizure during my exam that day. As I approached my second patient’s room to perform a liver Doppler, a doctor sitting outside of the room informed me the patient had just passed away. My third patient was about to receive a Foley catheter and was extremely nervous. Her nurse asked me to help assist before I started my ultrasound. The patient was still very nervous so I went to the hallway to find extra help. I asked an employee there if she wouldn’t mind coming in and holding the patient’s hand. She looked behind herself and then back at me before stating, “I’m just EVS [environmental services] but I’m happy to help if it’s OK.” She donned a gown and jumped right in.

 

Angela Huang, BS, RDMS (AB,OB/GYN,PS), RVT, is a Diagnostic Medical Sonographer for a large research hospital in Chicago. She attended DePaul University for undergraduate studies where she majored in Biology. Huang went on to Sonography school at El Centro College in Dallas, Texas. Now, she has a 10-year-old son who keeps her laughing and they love to travel and explore.

Interested in learning more about COVID-19? Check out the following posts from the Scan:

 

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My Sonography Experience With COVID-19

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It is been almost 5 weeks since I got infected with SARS-CoV-2 (also known as COVID-19), my life-changing experience.1

The day all started, during my night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, most of my mild COVID-19 patients had these same cold-like symptoms, but some of them did not have a known epidemiological contact. Without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally, it came in the midst of the night; I received the “positive”.

In the morning, as more symptoms started to appear, headache, diarrhea, anosmia, ageusia and dry cough, it was a relief to have my hand-held ultrasound device at home. With the rush, I even left my oximeter, which measures heart rate and blood oxygen levels, in my hospital locker.

There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan and X-ray. With my ultrasound probe, I scanned following 8 zones (2 anterior, 2 lateral of both hemithorax) plus posterior lobes. I felt relieved (didn’t last long) to see there was a normal A-line pattern. More relief came when at some point I had a dull but constant right lower abdominal pain with normal appendix and no hydronephrosis on ultrasound.

 

What impresses most about this disease is its dynamic pattern, with sudden changes during the evolution. As my symptoms waxed and waned, so did my lung ultrasound, probably in a different manner than I would have expected. As the disease progressed, I saw all the possible lung findings, from the initial posterobasal scattered B-lines, to small pleural effusions, irregular pleural line, coalescent B-lines, and finally subpleural consolidations, especially in posterior and lateral areas. My personal impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. After the second week, the subpleural consolidations were replaced by coalescent and scattered B-lines. Following that, the irregular pleural line persisted longer.

March 22 still

 

Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics.

My personal feeling is that consolidations are more reliable than just the number of B-lines, and correlated better with my symptoms. Actually, after 3 weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with scattered and coalescent B-lines, as well as thickening of the pleural line. We have to be more flexible and take into account other parameters (i.e. oximetry), rather than rely solely on the number of affected areas on ultrasound, to compose the clinical picture, and influence the management.

As I remarked before, what impresses me most about this disease is the ultrasound dynamism. After having recovered, I still had new areas of thickening of pleural line that appeared in the back (asymptomatic) for the following week (4th), and almost 5 weeks after, I still had one plaque. And after 5 weeks, I am still surprised to have unnoticed findings, such as an asymptomatic pericardial effusion.

As a firm sonobeliever, I found it extremely useful to monitor my disease for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, in the same way I went through.

Definitely, this experience was the best lesson I could have before returning to the trenches.

 

Yale Tung Chen, MD, PhD, is an associate professor at Universidad Alfonso X El Sabio, in Madrid, Spain. He was diagnosed with COVID-19 and shared his symptoms and ultrasound images each day on Twitter @yaletung. Follow his thread at #mycoviddiary.

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan: