Risk Stratification in COVID-19 Pneumonia – Determining the Role of Lung Ultrasound

Abstract

LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings.

Materials and Methods An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2^nd to April 3^rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER).

Results 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967.

Conclusion The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.

Zusammenfassung

LUS-Muster einer COVID-19-Pneumonie wurden beschrieben und erwiesen sich als charakteristisch. Ziel der Studie war es, die Prognose von Patienten mit COVID-19-Pneumonie durch einen auf LUS-Befunden basierenden Score vorherzusagen.

Material und Methoden Eine retrospektive Beobachtungsstudie wurde an Patienten durchgeführt, die im Zeitraum eines Monats vom 2. März bis 3. April 2020 mit der Diagnose einer COVID-19-Pneumonie in das Niguarda-Krankenhaus eingeliefert wurden. Demografische Daten, klinische, labortechnische und radiologische Befunde wurden erhoben. LUS wurde bei allen Patienten durchgeführt. Der Thorax wurde in 12 Areale unterteilt. Der LUS-Bericht wurde anhand eines Scores von 0 bis 3 erstellt, wobei 0 einem A-Muster entspricht, 1 gut abgegrenzten vertikalen Artefakten (B-Linien), 2 einer weißen Lunge und kleinen Konsolidierungen, 3 größeren Konsolidierungen. Der Gesamtscore ergibt sich aus der Summe der Scores für jedes Areal. Der primäre Endpunkt war die endotracheale Intubation (ETI), keine weiteren aktiven Maßnahmen oder der Tod. Der sekundäre Endpunkt war die Entlassung aus der Notaufnahme.

Ergebnisse 255 Patienten wurden in die Studie aufgenommen; 93,7 % davon hatten einen positiven LUS. Bei 43 Patienten wurde eine ETI durchgeführt, bei 24 gab es eine DNI (Do-not-intubate)-Anordnung. Die allgemeine Sterblichkeitsrate betrug 15,7 %. Männliches Geschlecht (OR 3,04; p = 0,014), kardiovaskuläre Erkrankungen und Hypertonie (OR 2,75; p = 0,006), P/F (OR 0,99; p < 0,001) und ein LUS-Score > 20 (OR 2,52; p = 0,046) waren unabhängige Risikofaktoren, die mit dem primären Outcome assoziiert waren. Die ROC-Kurvenanalyse (Receiver Operating Characteristic) für einen LUS-Score > 20 ergab einen AUC von 0,837. Unabhängige, mit dem sekundären Outcome assoziierte Risikofaktoren waren Alter (OR 0,96; p = 0,073), BMI (OR 0,87; p = 0,13), P/F (OR 1,03; p < 0,001) und LUS-Score < 10 (OR 20,9; p = 0,006). Die ROC-Kurvenanalyse unter Verwendung eines LUS-Scores < 10 ergab einen AUC von 0,967.

Schlussfolgerung Das Ausmaß der Lungenanomalien, die mittels LUS-Score bewertet wurden, ist ein Prädiktor für ein schlechteres Outcome, ETI oder Tod. Darüber hinaus könnte der LUS-Score eine Zusatzmethode für die sichere Entlassung von Patienten aus der Notaufnahme sein.

Key words

chest - point of care - echocardiography

Publication History

Received: 25 July 2020

Accepted: 19 December 2020

Article published online:
18 February 2021

• References

• 1 Huang C, Wang Y, Li X. et al Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497-506 DOI: 10.1016/S0140-6736(20)30183-5.
• 2 Ong SWX, Young BE, Leo YS. et al Association of higher body mass index (BMI) with severe coronavirus disease 2019 (COVID-19) in younger patients [published online ahead of print, 2020 May 8]. Clin Infect Dis 2020; DOI: 10.1093/cid/ciaa548.
• 3 Sun H, Ning R, Tao Y. et al Risk Factors for Mortality in 244 Older Adults With COVID-19 in Wuhan, China: A Retrospective Study [published online ahead of print, 2020 May 8]. J Am Geriatr Soc 2020; DOI: 10.1111/jgs.16533.
• 4 Henry BM, de Oliveira MHS, Benoit S. et al Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis [published online ahead of print 2020 Apr 10]. Clin Chem Lab Med 2020; DOI: 10.1515/cclm-2020-0369.
• 5 Liang W, Liang H, Ou L. et al Development and Validation of a Clinical Risk Score to Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19 [published online ahead of print, 2020 May 12]. JAMA Intern Med 2020; e202033 DOI: 10.1001/jamainternmed.2020.2033.
• 6 Colombi D, Bodini FC, Petrini M. et al Well-aerated Lung on Admitting Chest CT to Predict Adverse Outcome in COVID-19 Pneumonia [published online ahead of print, 2020 Apr 17]. Radiology 2020; 201433 DOI: 10.1148/radiol.2020201433.
• 7 Mayo PH, Copetti R, Feller-Kopman D. et al Thoracic ultrasonography: a narrative review. Intensive Care Med 2019; 45: 1200-1211 DOI: 10.1007/s00134-019-05725-8.
• 8 Volpicelli G, Elbarbary M, Blaivas M. et al International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577-591 DOI: 10.1007/s00134-012-2513-4.
• 9 Xirouchaki N, Magkanas E, Vaporidi K. et al Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med 2011; 37: 1488-1493 DOI: 10.1007/s00134-011-2317-y.
• 10 Yang Y, Huang Y, Gao F. et al Lung ultrasonography versus chest CT in COVID-19 pneumonia: a two-centered retrospective comparison study from China [published online ahead of print 2020 May 25]. Intensive Care Med 2020; 1-3 DOI: 10.1007/s00134-020-06096-1.
• 11 Peng QY, Wang XT, Zhang LN. et al Findings of lung ultrasonography of novel coronavirus pneumonia during the 2019-2020 epidemic. Intensive Care Med 2020; 46: 849-850 DOI: 10.1007/s00134-020-05996-6.
• 12 Poggiali E, Dacrema A, Bastoni D. et al Can Lung US Help Critical Care Clinicians in the Early Diagnosis of Novel Coronavirus (COVID-19) Pneumonia?. Radiology 2020; 295: E6 DOI: 10.1148/radiol.2020200847.
• 13 Soldati G, Smargiassi A, Inchingolo R. et al Is There a Role for Lung Ultrasound During the COVID-19 Pandemic? [published online ahead of print 2020 Mar 20]. J Ultrasound Med 2020; DOI: 10.1002/jum.15284.
• 14 Volpicelli G, Lamorte A, Villén T. What's new in lung ultrasound during the COVID-19 pandemic [published online ahead of print 2020 May 4]. Intensive Care Med 2020; 1-4 DOI: 10.1007/s00134-020-06048-9.
• 15 WHO. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance, 25 January 2020. Published January 25, 2020; accessed 2020 March 30
• 16 Dargent A, Chatelain E, Kreitmann L. et al Lung ultrasound score to monitor COVID-19 pneumonia progression in patients with ARDS. PloS one 2020; 15: e0236312 . doi.org/10.1371/journal.pone.0236312
• 17 Perrone T, Soldati G, Padovini L. et al A New Lung Ultrasound Protocol Able to Predict Worsening in Patients Affected by Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia. J Ultrasound Med 2020; 9999: 1-9 DOI: 10.1002/jum.15548.
• 18 Buonsenso D, Raffaelli F, Tamburrini E. et al Clinical role of lung ultrasound for the diagnosis and monitoring of COVID-19 pneumonia in pregnant women [published online ahead of print 2020 Apr 26]. Ultrasound Obstet Gynecol 2020; DOI: 10.1002/uog.22055.
• 19 Parri N, Magistà AM, Marchetti F. et al Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian pediatric research network. [published online ahead of print 2020 June 3]. Eur J Pediatrics 2020; DOI: 10.1007/s00431-020-03683-8.
• 20 Smith MJ, Hayward SA, Innes SM. et al Point-of-care lung ultrasound in patients with COVID-19 – a narrative review [published online ahead of print 2020 Apr 10]. Anaesthesia 2020; DOI: 10.1111/anae.15082.
• 21 Osterwalder J. COVID-19 – More Lung Pocus and Sparing Use of Stethoscope, Chest X-Ray and Lung CT [published online ahead of print 2020 May 1]. Praxis (Bern 1994) 2020; 1-9 DOI: 10.1024/1661-8157/a003512.
• 22 Via G, Storti E, Gulati G. et al Lung ultrasound in the ICU: from diagnostic instrument to respiratory monitoring tool. Minerva Anestesiol 2012; 78: 1282-1296
• 23 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 [published online ahead of print 2020 Mar 30]. J Ultrasound Med 2020; DOI: 10.1002/jum.15285.
• 24 Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not?. Crit Care 2020; 24: 154 . Published 2020 Apr 16 DOI: 10.1186/s13054-020-02880-z.
• 25 Cummings MJ, Baldwin MR, Abrams D. et al Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study [published online ahead of print 2020 May 19]. Lancet 2020; DOI: 10.1016/S0140-6736(20)31189-2.
• 26 Grasselli G, Zangrillo A, Zanella A. et al Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy [published online ahead of print 2020 Apr 6]. JAMA 2020; 323: 1574-1581 DOI: 10.1001/jama.2020.5394.
• 27 Li X, Zeng W, Li X. et al CT imaging changes of corona virus disease 2019(COVID-19): a multi-center study in Southwest China. J Transl Med 2020; 18: 154 . Published 2020 Apr 6 DOI: 10.1186/s12967-020-02324-w.
• 28 Shi H, Han X, Jiang N. et al Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis 2020; 20: 425-434 DOI: 10.1016/S1473-3099(20)30086-4.