Lung Ultrasound to Diagnose COVID-19 (Coronavirus Lecture 51)
Welcome to another MedCram covid-19 update. If we look at yesterday’s, we had a total of thirty thousand new cases in the United States, and France with 5,000. Take a quick look at the United States, New York is at the top, and they are supposed to peak around April 9 or 10, California is supposed to peak around April 26.
Testing has been a big issue. Here recently, if you look at the total number of tests per million population, you can see that New York is followed by Louisiana, and of course, Washington, which is really where things started in the first place. Interestingly, if you look and see where California is on the other hand, it’s way down near the bottom of the list, with only 3,313 tests per 1 million population being performed.
If you look at where the new deaths are coming from in the States, we have the average here “USA Total”, but if you look at the death per million population, the average is around 33. Those states with a higher than average death per million population are listed here, and these states here are less than the national average. And that could very well be because of where they are in a position of surge. These states here are going to be surging later, and I’m sure there’s going to be a flip-flop of these states relative to the neighbors above the average. We will talk more about surging, and peaking and resources.
So I want to show you this very interesting and useful website. This is put out by the University of Washington. It basically is a model that will tell you when the pandemic of Covid-19 is going to peak in terms of resources and in terms of deaths. And it’s being constantly updated in real-time by real data.
The Covid-19 projections here are assuming full social distancing through May of 2020, and there’s a FAQ here. But what you can do as you can see here is you can put in the district that you like to look at. Here is the United States of America, and it will tell you here nine days until the peak resource use on April 15. It’ll show you how many beds are needed, what the bed shortage is nationally, ICU beds that are needed, the ICU bed shortage, and the number of ventilators that are needed.
这里的Covid-19预测假设到2020年5月将全部实施社交隔离，并且这里有一个常见问题解答。但是，你可以在这里看到的是你可以放入要查看的区域。这是美国，它提前9天告诉你， 资源使用会4月15日达到高峰。它将向你显示需要多少张床，全国范围的床短缺情况，需要的ICU床， ICU床短缺，以及需要的呼吸机数量。
You can actually see it here in the graph. You can click on “All Beds,” what the predicted will be, and the range of those from top to bottom, and then the number of invasive ventilators. If we scroll down, here we can see the number of deaths per day. As you can see here, the solid red line is real data. And after it, is projected data based on the models that the computers have run.
你实际上可以在图中的此处看到它。你可以单击“ All Beds”，这将是预期的值，上下的范围以及手术呼吸机的数量。如果向下滚动，则可以在这里看到每天的死亡人数。如你在此处看到的，红色实线是实际数据，之后就是根据计算机运行的模型预测的数据。
Now, of course, this is the United States of America. What we can do is we can go and see what things are like in your particular state. You can do that here on the website. Let’s go to New York, which has been in the news recently. Of course, they are ahead of us in terms of the curve.
You can also see here what happened in the state in terms of what date, so you can see here on March 22nd, for instance, was the stay-at-home order; on March 18 had educational facilities that were closed. If we look at “All Beds,” we can see that the number of beds that will be needed peak here on April 9th, which is just a few days away, then come back down.
你还可以在这里看到该州在哪一天发生了什么，因此，例如3月22日，你可以在此看到“待在家里”的命令； 3月18日，教育设施被关闭。如果我们查看“All Beds”，则可以看到需要的床铺数量在4月9日（离现在只有几天）达到顶峰，然后下降。
There is a bar which is the beds that are available, and you can see that we’re already exceeding the beds that are at least available based on the model. We can look at the number of ICU beds. The number of ICU beds far exceeded, and you can see those are the kind of issues that they’re having in New York.
In terms of deaths per day, you can see where we are right now and where things are predicted to be. If we go to, for instance, my neck of the woods in California, you can see things not as severe as what’s going on in the Eastern Seaboard there. We are predicted to peak in California in terms of resources on April 14, and you can see the resources here that will be needed.
If we go to ‘All Beds,’ apparently here in California we are well under that bar, so we should be able to meet that in terms of ICU beds according to this model, we should be able to meet the demands. So we’re all watching this as participants on the front lines, as healthcare providers because we want to know exactly when this peak is going to come, and when we can expect things to subside.
And with this pandemic have come difficulties in terms of diagnostics. How do you image the lung and how do you deal with the contamination issues when you’re taking somebody from one room to another. You know, one of the modalities of imaging that we had to use quite a bit of this last week in the hospital was the CAT scanner. It’s a very integral part of the system that we use.
The problem, however, is that anybody that comes into the emergency room that has a cough, or a fever, or even less than that, is going to be considered as a person of interest in terms of being infected. The term that we use is a PUI or a person or patient under investigation.
The problem with that is that when you send that patient to the CAT scanner, they do the CAT scan, but then they have to spend the next hour or so wiping down that CAT scanner because if it turns out that the first patient is positive, and the next person that comes in is not, then you could spread that virus to that patient. So the number of CAT scans that you can do on a regular basis is really reduced and that can impede your ability to do appropriate work up in the emergency room.
Something that’s much quicker, much easier to wipe down, and something that’s portable, that you could even put a transparent plastic cover over it and go from room to room simply changing the plastic cover is an ultrasound. Well, as you know, as they say “necessity is the mother of invention.” And in this case, the inventions have already been made. It’s just that we’re getting more creative. And even more so a portable ultrasound machine that can be hooked up to a small device or iPad is even more convenient and can be wiped down very quickly.
Now, I want you to understand what’s going on with ultrasound in Covid-19. And the best person to do that is the one who taught me ultrasound. Dr. Joshua Jacquet is the Emergency Ultrasound Director at the Cleveland Clinic Akron General in Akron, Ohio. You can read more about Dr. Jacquet on our website, but let’s get a better understanding of what’s going on with ultrasound in Covid-19.
Well, thank you Roger. I just want to take a second to appreciate you in the MedCram team for all that you’ve done to release these amazing Covid-19 update videos. As I’ve been following along with you, I’ve wanted to discuss lung ultrasound. Before the pandemic, I utilized lung ultrasound in the care of my Emergency Department patients routinely, mostly the diagnose of respiratory illnesses, and that’s because it’s more accurate than a chest x-ray which we routinely use and more accurate than our stethoscope. And it rivals the accuracy of CT Imaging. So it’s not surprising to me that in the Covid-19 pandemic people are starting to utilize lung ultrasound more because of its advantages.
You can see in this article Ultrasound useful for detecting Covid-19 pneumonia emergency medicine providers say and this is a group of Italian Imaging experts and they’re using the word here urging for ultrasound as one possible alternative.
So why would these Imaging experts urge us to be utilizing lung ultrasound？ Roger, you already did a video that describe the advantages of CT in the accuracy early in the Covid-19 illness. But CT has some major disadvantages. And here’s a paper “Findings of lung ultrasonography of novel coronavirus pneumonia.” This was published in intensive care medicine. And the primary purpose of this study was to compare the CT findings with the lung ultrasound findings. So if CT is accurate and we can compare the findings, then we can suspect that lung ultrasound is accurate.
So the reason I bring out this article here is because they considered in their experience lung ultrasound to have major utility in the management of these patients due to some advantages, they point out it’s safe. There’s no radiation. Radiation increases your cancer risk over time and chest x-ray and CT both use radiation. It’s repeatable, meaning you can do the exam as many times as you clinically need to and repeat it quickly. It’s low cost compared to other imaging.
You can use it at point of care, meaning right at the bedside I can get information that will help me manage my patient. You can do a rapid assessment of the patient at presentation. You can track the evolution of the disease. So in real time, if there’s a change, it’ll show up on lung ultrasound. And then they point out many other decisions that the doctors have to make, especially in the Intensive Care Unit. Those decisions, many times, are complicated, and ultrasound can be used as a piece of the puzzle to help make those decisions.
So here’s another article. This is a correspondence published in the Lancet by several Italian doctors encouraging us. In this Covid-19 outbreak, use less stethoscope and more ultrasound. “Is lung ultrasound the stethoscope of the new millennium? Definitely yes.” And so they’re showing the advantages of using a portable ultrasound system. We see a picture of it here where you could have a tablet and a ultrasound probe attached by Bluetooth or Wi-Fi.
And you can cover these with sterile covers, so as not to transmit the infection to another patient after you’re done. And so they point out here in their opinion the use of ultrasound is now essential in the safe management of Covid-19 outbreaks, since it can allow can common execution of clinical examination and lung imaging at the bedside by the same doctor, meaning the doctor can come in, talk to you, do the exam and get lung imaging with ultrasound right there instead of having to send you to chest x-ray or CAT scan.
And here’s another video showing the advantage of having a portable device. You can cleanse and disinfect it and cover the entire thing in a sterile cover. So if you go into the hospital or in a triage setting and you need to get an ultrasound, this is just a little bit of what that might look like. So the probe just touches your body, there’s gel between the ultrasound probe and you, and then the machine shows a picture of what your lungs look like on the inside.
So this is one of the first articles that describes the lung ultrasound findings in Covid-19. They looked at 20 patients in China and compared their CT images with their ultrasound images. And just to give you an idea, on CAT scan this white patchy area‘s where Covid-19 is affecting the lung, and on ultrasound that may appear like these vertical white lines, which we call B lines coming down from the lining of the lung. On another patient, this white patchy area here and here are both areas where Covid-19 is affecting the lungs, and on lung ultrasound you see this irregularity of the lining of the lung and this kind of white out shadow area that it produces.
So on this patient, you see more this white rounded consolidated area in Cat Scan with these black lines, which is air still trying to get into that area of the lung, and on lung ultrasound that shows up as this kind of dark blob here with these white dots inside which are air on ultrasound.
So how might you see health care providers using lung ultrasound in Covid-19. Well, as discussed, they may use it in triage when they’re seeing a bunch of patients instead of chest x-ray or CAT scan and that may help us know how severe the illness already is and who is at risk for it getting worse. We may be able to also utilize it while we’re waiting for that PCR test to know if that’s positive or negative.
And here’s an article showing an example of this. Under pressure one Italian doctor triage is by ultrasound. Other area is “can ultrasound help us predict who is going to get worse before they do?” Most believe that it’s very advantageous to follow the progression of the disease and as we talked about before, it can help make some of the tough decisions that we need to make in these Covid-19 patients.
And remember it’s not just patients that are being affected by this pandemic, but healthcare providers are as well. Here’s an example of Dr. Yale Chen, who contracted Covid-19. He’s an emergency physician in Spain and he shares a diary on Twitter daily of his symptoms and his lung ultrasound findings. So as we’re following the progression of his symptoms while he’s at home, we’re also able to follow the progression of his lung ultrasound findings and learn from him both how he’s feeling in the progression of disease as well as the progression of his lung ultrasound findings.
So for all the reasons we discussed today, you’re going to see lung ultrasound utilized in Covid-19 more and more. Now, if you’re a health care professional and you need to learn more about lung ultrasound, there are many resources. So at MedCram, we’ve released lung ultrasound and Covid-19 educational videos. We’ve added them to our lung ultrasound explained clearly course and we’ll also release them separately on YouTube. These will be free and open access to any provider who’d like to educate themselves on how to utilize lung ultrasound in Covid-19.
So we are praying that this virus is eradicated and this pandemic ceases, but in the meantime healthcare professionals are utilizing every resource at their fingertips to take the best care of their patients.