Ultrasound in COVID-19: a timeline of ultrasound findings in relation to CT
2020; Elsevier BV; Volume: 75; Issue: 7 Linguagem: Inglês
10.1016/j.crad.2020.04.003
ISSN1365-229X
Autores Tópico(s)Thermal Regulation in Medicine
ResumoSir—The novel coronavirus (Sars-Cov-2) produces a mild to severe lower respiratory tract infection that is commonly identified by imaging in affected patients, in some cases even before symptom development.1Jin Y. Cai L. Cheng Z.S. et al.Zhongnan hospital of Wuhan university novel coronavirus management and research team; evidence-based medicine chapter of China international exchange and promotive association for medical and health care (CPAM). A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).Mil Med Res. 2020; 7: 4Crossref PubMed Scopus (1557) Google Scholar Computed tomography (CT) has been the primary imaging method evaluated to date and is often being recommended as a screening tool for patients suspected of having COVID-19.2National Health Commission of the people's Republic of ChinaDiagnosis and treatment of novel coronavirus pneumonia.http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440.shtmlGoogle Scholar Lung ultrasound is an alternative imaging method with emerging evidence that supports its ability to identify characteristic lesions seen in COVID-19 that are highly consistent with CT imaging,3Huang Y. Wang S. Liu Y. et al.A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).SSRN. 2020; : 3544750https://doi.org/10.2139/ssrn.3544750Crossref Scopus (0) Google Scholar,4Poggiali 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; : 200847https://doi.org/10.1148/radiol.2020200847Crossref PubMed Scopus (239) Google Scholar without many of the downsides. For clinicians wishing to use ultrasound in the management of patients with COVID-19, it is important to understand the characteristic findings and the timeline in which they would occur. These are described below in comparison to CT. It is estimated that lung abnormalities present early in the course of disease with bilateral, basal, and peripheral involvement in approximately 50–75% of patients5Bernheim A. Mei X. Huang M. et al.Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection.Radiology. 2020; : 200463https://doi.org/10.1148/radiol.2020200463Crossref PubMed Scopus (1851) Google Scholar,6Kanne J. Little B. Chung J. et al.Essentials for radiologists on COVID-19: an update—radiology scientific expert panel.Radiology. 2020; : 200527https://doi.org/10.1148/radiol.2020200527Crossref PubMed Scopus (512) Google Scholar and occur in identifiable stages. Using CT, Jin et al. described five temporal stages of the disease in the lungs as ultra-early (asymptomatic, 1–2 weeks after exposure), early (1–3 days from symptom presentation), rapid progression (3–7 days from symptom presentation), consolidation (7–14 days from symptom presentation), and dissipation (2–3 weeks after symptom onset), each occurring with associated findings.1Jin Y. Cai L. Cheng Z.S. et al.Zhongnan hospital of Wuhan university novel coronavirus management and research team; evidence-based medicine chapter of China international exchange and promotive association for medical and health care (CPAM). A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).Mil Med Res. 2020; 7: 4Crossref PubMed Scopus (1557) Google Scholar Similar categories were described by Pan et al. with the exception of a pre-symptomatic phase.7Pan F. Ye T. Sun P. et al.Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia.Radiology. 2020; : 200370https://doi.org/10.1148/radiol.2020200370Crossref PubMed Scopus (1889) Google Scholar CT findings begin as single or multifocal ground-glass opacities, pulmonary nodules, or air bronchograms, which progress with development of interlobular septal thickening and crazy paving, before regression in both size and density at the end of the second week of infection. Opacities often have extensive distribution, typically bilaterally, but also seen unilaterally, with occasional round morphology or reversed-halo or atoll sign.5Bernheim A. Mei X. Huang M. et al.Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection.Radiology. 2020; : 200463https://doi.org/10.1148/radiol.2020200463Crossref PubMed Scopus (1851) Google Scholar In the dissipation phase, there may be continued patchy consolidative opacities in addition to reticular "strip-like" opacities, bronchial wall thickening, and interlobular septal thickening.1Jin Y. Cai L. Cheng Z.S. et al.Zhongnan hospital of Wuhan university novel coronavirus management and research team; evidence-based medicine chapter of China international exchange and promotive association for medical and health care (CPAM). A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).Mil Med Res. 2020; 7: 4Crossref PubMed Scopus (1557) Google Scholar,8Salehi S. Abedi A. Balakrishnan S. et al.Coronavirus disease 2019 (COVID-19): a systematic review of imaging findings in 919 patients.AJR Am J Roentgenol. 2020; : 23034Google Scholar The characteristic ultrasound findings (bilateral and multilobar B-lines, subpleural consolidates, irregular pleural line, and decreased blood flow3Huang Y. Wang S. Liu Y. et al.A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).SSRN. 2020; : 3544750https://doi.org/10.2139/ssrn.3544750Crossref Scopus (0) Google Scholar,4Poggiali 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; : 200847https://doi.org/10.1148/radiol.2020200847Crossref PubMed Scopus (239) Google Scholar,9Peng Q. Wang X. Zhang L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.Intensive Care Med. 2020; https://doi.org/10.1007/s00134-020-05996-6Crossref Scopus (571) Google Scholar) have been shown to be highly consistent with CT findings3Huang Y. Wang S. Liu Y. et al.A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).SSRN. 2020; : 3544750https://doi.org/10.2139/ssrn.3544750Crossref Scopus (0) Google Scholar,4Poggiali 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; : 200847https://doi.org/10.1148/radiol.2020200847Crossref PubMed Scopus (239) Google Scholar and can be expected to develop over a similar timeline. During the first few days of symptom presentation, scattered unilateral or bilateral multilobar B-lines can be visualised.3Huang Y. Wang S. Liu Y. et al.A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).SSRN. 2020; : 3544750https://doi.org/10.2139/ssrn.3544750Crossref Scopus (0) Google Scholar,9Peng Q. Wang X. Zhang L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.Intensive Care Med. 2020; https://doi.org/10.1007/s00134-020-05996-6Crossref Scopus (571) Google Scholar As the disease progresses from the end of week 1 through week 2, development of alveolar interstitial syndrome with diffuse, bilateral B-lines can occur in addition to an irregular pleural line with punctate defects and formation of subpleural consolidations with visible air bronchograms. Lastly, after the end of week 2 during convalescence, there can be an expected regression of prior findings with re-emergence of A-lines.9Peng Q. Wang X. Zhang L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.Intensive Care Med. 2020; https://doi.org/10.1007/s00134-020-05996-6Crossref Scopus (571) Google Scholar A summary of findings is listed in Table 1.Table 1Timeline of common findings of COVID-19 in computed tomography (CT) and ultrasound.1Jin Y. Cai L. Cheng Z.S. et al.Zhongnan hospital of Wuhan university novel coronavirus management and research team; evidence-based medicine chapter of China international exchange and promotive association for medical and health care (CPAM). A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version).Mil Med Res. 2020; 7: 4Crossref PubMed Scopus (1557) Google Scholar,3Huang Y. Wang S. Liu Y. et al.A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).SSRN. 2020; : 3544750https://doi.org/10.2139/ssrn.3544750Crossref Scopus (0) Google Scholar, 4Poggiali 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; : 200847https://doi.org/10.1148/radiol.2020200847Crossref PubMed Scopus (239) Google Scholar, 5Bernheim A. Mei X. Huang M. et al.Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection.Radiology. 2020; : 200463https://doi.org/10.1148/radiol.2020200463Crossref PubMed Scopus (1851) Google Scholar, 6Kanne J. Little B. Chung J. et al.Essentials for radiologists on COVID-19: an update—radiology scientific expert panel.Radiology. 2020; : 200527https://doi.org/10.1148/radiol.2020200527Crossref PubMed Scopus (512) Google Scholar, 7Pan F. Ye T. Sun P. et al.Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia.Radiology. 2020; : 200370https://doi.org/10.1148/radiol.2020200370Crossref PubMed Scopus (1889) Google Scholar, 8Salehi S. Abedi A. Balakrishnan S. et al.Coronavirus disease 2019 (COVID-19): a systematic review of imaging findings in 919 patients.AJR Am J Roentgenol. 2020; : 23034Google Scholar, 9Peng Q. Wang X. Zhang L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.Intensive Care Med. 2020; https://doi.org/10.1007/s00134-020-05996-6Crossref Scopus (571) Google ScholarSymptom onset (days)CTUltrasound0–3Single or multiple scattered and patchy GGO, patchy grid-like thickness of interlobular septaUnilateral or bilateral focal B-lines3–7Fused and large-scale consolidation with internal air bronchograms, crazy-paving pattern, multi-lobe GGOBilateral diffuse B-lines with irregular pleural line and punctate defects, subpleural consolidations, air bronchograms7–14Multiple patchy consolidations that are reduced in size and density, crazy-paving pattern14–21Reduced patchy consolidations, strip-like opacities, grid-like thickening of interlobular septum, minimal crazy pavingResolving consolidations, A-linesGGO, ground-glass opacity. Open table in a new tab GGO, ground-glass opacity. Although the literature remains limited, there is still a clear benefit for clinicians to be familiar with ultrasound findings and their progression in COVID-19 patients. It may be particularly useful in helping emergency personnel to triage and diagnose suspected patients,4Poggiali 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; : 200847https://doi.org/10.1148/radiol.2020200847Crossref PubMed Scopus (239) Google Scholar but also for monitoring progression of the disease throughout hospitalisation. Additionally, it offers substantial benefits in comparison to CT imaging, including portability, lower cost, reduced radiation, and ease of sterilisation. Physicians are encouraged to be familiar with and to utilise lung ultrasound in the management of COVID-19 patients. The author declares no conflict of interest.
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