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

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