Under Pressure, One Italian Doctor Triages by Ultrasound

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MARCH 24, 2020 -- Patients have been arriving at the emergency department of the University Hospital San Luigi Gonzaga, in Turin, Italy, one after another after another. At first, physicians thought advanced age was a good predictor of which cases might go downhill fast. They were wrong. "We intubated a woman who was 38 years old," says Giovanni Volpicelli, MD. "We see otherwise healthy patients with acute symptoms of pneumonia due to the virus." And the more patients they see, he says, "the more we see that anyone over 30 is affected."

Because they couldn't use age nor underlying condition to predict which patients would develop severe COVID-19-associated pneumonia, they needed a new approach. That's what led Volpicelli, a leading expert in treating patients on the coronavirus front lines, to develop a method that can separate out the lethal from the less dangerous cases: triage via ultrasound.

The technique has not yet been peer reviewed, but Volpicelli and his colleagues are now convinced that lung ultrasounds should be done at the bedside for all patients suspected of infection with the novel coronavirus. Even people with mild symptoms, he says, could harbor lung disease that quickly leads to severe pneumonia and respiratory failure. In his experience, ultrasound assessment effectively separates those who need to be admitted from those who can be sent home to convalesce under quarantine.

Building a Triage Protocol

He and his team have developed a standard approach that starts with a nurse classifying patients based on whether they have fever, cough, or labored breathing — just one of those symptoms is enough to prompt suspicion and the patient is moved into isolation. Then, Volpicelli says, after an examination, "the first thing we do is lung ultrasound."

That's because, as the pandemic tore through his city, he began to see that so many patients presented with a negative chest X-ray but a lung ultrasound that was positive for interstitial pneumonia. Ultrasounds, he discovered, were very useful to both screen for and diagnose someone with the disease. "Only by using a test that can assess the situation of the lung at the beginning of the disease do you become aware that pneumonia can also be present…even in patients with mild or almost no symptoms — just a little bit of fever," Volpicelli says. 

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More often than not, an ultrasound is negative and emergency department staff continue their diagnostics. They swab nasal passages for testing with RT-polymerase chain reaction (rRT-PCR), then they send the patient home to wait for test results in isolation.

But if a lung ultrasound indicates pneumonia, he and his staff add a chest X-ray and blood tests to the COVID-19 PCR testing. Until results come back, 24-36 hours later, they keep the patient isolated in the hospital rather than sending them home. "Patients who are positive for pneumonia, even if they’re not severely symptomatic, are…in danger of developing more severe pneumonia and respiratory failure," Volpicelli says.

And, at least while space remains, they can afford to admit patients with "highly suggestive" ultrasound results, even before a positive COVID-19 test comes back. Then, they start treatment with an antiviral and hydroxychloroquine. "While the approach is still unproven for treating COVID-19, on-the-ground experience of physicians in China and Europe suggest that potential benefits may outweigh potential risks, at least for now."

Ultrasound a Growing Trend

Other clinicians and scientists in Italy have also been using their experience with lung ultrasound to assess suspected COVID-19 patients and develop standardized approaches and protocols.

Libertario Demi, PhD, head of the Ultrasound Laboratory Trento at the University of Trento, Italy, has been collaborating with a team of clinicians and scientists from across the country. This week, they published a Clinical Letter in the Journal of Ultrasound Medicine on the role of lung ultrasound during the COVID‐19 pandemic, as well as an article in Ultrasound in Obstetrics and Gynecology on how to perform lung ultrasound in pregnant women with suspected COVID-19 infection. A second paper, accepted by the Journal of Ultrasound Medicine, is due for publication this week and sets out a simple, quantitative, and reproducible method for performing lung ultrasound in COVID-19 patients.

Demi agrees with Volpicelli’s approach. And he stresses the importance of having measurements from hospitals across the country, as a way to combine "the experience that we have developed together, as clinicians and technicians."

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Ultrasound technology was designed to examine organs such as the heart or a pregnant woman's womb — soft tissues that, "acoustically speaking, look like water," Demi says. But lungs are full of air, making analysis completely different. So he and his colleagues are working on algorithms that can interpret ultrasound artefacts automatically, building on a database hosted by his lab of more than 60,000 images obtained from patients infected with COVID-19. "This is really a national effort," he said, that involves hospitals from across Italy.

Adapting the Hospital Step by Step

Volpicelli's hospital has shifted in other ways as well to accommodate the COVID-19 surge, such as by setting up a sub-intensive ward within the emergency department that is completely dedicated to coronavirus patients. "It's where, for instance, we admit patients with severe respiratory failure needing CPAP [continuous positive airway pressure] or any kind of noninvasive ventilation," Volpicelli says.

The hospital has transformed standard wards in the pulmonology and internal medicine departments into COVID-19-only units. And the intensive care unit is now given over entirely to COVID-19 patients, so only those who test positive are intubated and admitted.

As the number of COVID-19 patients increases, Volpicelli says, "we are adapting the hospital step by step."

They've also adopted and maintained strict infection control protocols. In fact, he believes their emergency department is not only the safest place in the hospital but in the town. "We protect ourselves, and we protect all the areas and all the machines we use to examine patients," Volpicelli says. "So far, I can say that not one of my team became infected."

Total Transformation of Hospital: "It Is Another Place"

Volpicelli explained that, before the coronavirus outbreak, his hospital was a typical tertiary referral center, seeing patients "of any kind," such as trauma, oncology, and chronic lung disease patients, as well as a dedicated mesothelioma facility, and a cardiology department, which saw "many patients with infarctions, embolisms, or any kind of pathology."

Since the arrival of COVID-19, however, his hospital, "changed 100%," he said, which is "amazingly, really, as I didn't think it was possible."

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"It is another place, another hospital. The population seems to be totally different because all the usual visits that we were doing before this storm, this surge, totally disappeared and we spend most of our time trying to understand if patients with respiratory symptoms are infected with the virus."

"I did my shift last night, and I saw only two patients without any respiratory problems."

"All the other patients, most of whom were positive for the infection, were complaining of respiratory symptoms, from just a fever and cough to severe, the most severe, cases of respiratory failure."

Volpicelli reiterated the fact that the patients he sees with COVID-19 sequelae encompass all age groups, from around 30 years of age to the "very elderly."

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