Monitoring of pulmonary involvement in critically ill COVID-19 patients - should lung ultrasound be preferred over CT?

Abstract

Background It is unclear if relevant changes in pulmonary involvement in critically ill COVID-19 patients can be reliably detected by the CT severity score (CTSS) and lung ultrasound score (LUSS), or if these changes have prognostic implications. In addition, it has been argued that adding pleural abnormalities to the LUSS could improve its prognostic value. The objective of this study was to compare LUSS and CTSS for the monitoring of COVID-19 pulmonary involvement through: first, establishing the correlation of LUSS (± pleural abnormalities) and CTSS throughout admission; second, assessing agreement and measurement error between raters for LUSS, pleural abnormalities, and CTSS; third, evaluating the association of the LUSS (± pleural abnormalities) and CTSS with mortality at different timepoints. Methods This is a prospective, observational study, conducted during the second COVID-19 wave at the AmsterdamUMC, location VUmc. Adult COVID-19 ICU patients were prospectively included when a CT or a 12-zone LUS was performed at admission or at weekly intervals according to local protocol. Patients were followed 90 days or until death. We calculated the: (1) Correlation of the LUSS (± pleural abnormalities) and CTSS throughout admission with mixed models; (2) Intra-class correlation coefficients (ICCs) and smallest detectable changes (SDCs) between raters; (3) Association between the LUSS (± pleural abnormalities) and CTSS with mixed models. Results 82 consecutive patients were included. Correlation between LUSS and CTSS was 0.45 (95% CI 0.31–0.59). ICCs for LUSS, pleural abnormalities, and CTSS were 0.88 (95% CI 0.73–0.95), 0.94 (95% CI 0.90–0.96), and 0.84 (95% CI 0.65–0.93), with SDCs of 4.8, 1.4, and 3.9. The LUSS was associated with mortality in week 2, with a score difference between patients who survived or died greater than its SDC. Addition of pleural abnormalities was not beneficial. The CTSS was associated with mortality only in week 1, but with a score difference less than its SDC. Conclusions LUSS correlated with CTSS throughout ICU admission but performed similar or better at agreement between raters and mortality prognostication. Given the benefits of LUS over CT, it should be preferred as initial monitoring tool.

Validation of New Quantitative Lung Ultrasound Protocol and Comparison With Lung Ultrasound Score in Patients With COVID-19

“…First, LUS requires greater pattern recognition experience, which limits its interrater reliability, particularly when differentiating between scores 1 and 2. 7 Second, LUS does not consider the burden of other common pathologies (eg, small consolidations, pleural effusions), which certainly cause a loss of aeration. Finally, the relative weight of separate patterns must be calibrated on relevant clinical outcome parameters.…”

“…Ultrasound examinations were performed by investigators using a dedicated ultrasound machine with previously described methodology. 7 Both LUS and LUSext are by definition surface samples of total pulmonary parenchyma. A 12-zone interspace examination may therefore be a representative surface sample provided that it would cover area along both anteroposterior and apical-basal axes of the lung.…”

“… 4 LUS may also be performed rapidly and has been validated for COVID-19 and non-COVID-19 ARDS and is associated with CTSS, Pa o 2 /F i o 2 ratio, extravascular lung water, length of stay, duration of ventilation, and mortality. 5 , 6 , 7 , 8 , 9 , 10 There are currently no studies that demonstrate association between LUSext and patient outcomes.…”