Ultrasound of the Week #016 – Under The Helipad

Case:

A 64 year old male with a PMH of asthma, hypertension and Type 2 Diabetes presented with gradual onset central chest tightness worse on exertion, associated shortness of breath and feeling hot for 8 days. He had no other symptoms of note.

Examination revealed scattered bibasal crackles on auscultation but no other abnormalities.

SpO2 93% RA, 80% on exertion. HR96, T37.5, RR20, BP 136/78.

He had a lung ultrasound and bedside echo:

Lung US:

Left lung

Right lung

[expand title=”Echo:” tag=”h2″]

PLAX

A4Ch

PSAX

[/expand] [expand title=”Interpretation:” tag=”h2″]

The echo is essentially normal, with no signs of right heart strain nor LV dysfunction. The focus here is on the lung ultrasound.

There are diffuse B-lines that in many places are coalescing, pleural irregularity and areas of sub-pleural consolidation. Remember, B-lines represent ‘alveolar-interstitial syndromes’ (pulmonary oedema, inflammation). We see these most commonly in pulmonary oedema. However, given a normal bedside Echo and especially the pleural thickening and sub-pleural consolidation, this is highly suggestive of a diffuse inflammatory process which in this case is most likely COVID-19 pneumonia.

This patient was admitted under the medical team. As he had a normal lymphocyte count, low CRP, was tachycardic and had pleuritic chest pain he had a CTPA which was reported as:

“No pulmonary embolism identified. Bilateral new peripheral ground-glass opacification is highly suspicious of COVID-19 pneumonia. Correlation with RT-PCR is recommended”

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[expand title=”Lung Ultrasound in COVID-19:” tag=”h2″]

Lung ultrasound has been put to great use in the COVID-19 pandemic in many countries, from streaming patients to tracking progression of disease in ICU and titrating therapy according to findings^[1], and more evidence continues to be published on it’s utility. The sensitivity of Lung Ultrasound for signs of viral pneumonia is considerably higher than chest XR^[2] and approaches that of CT.

The classic findings in viral pneumonia are^[3]:

B-lines, focal and confluent
Irregular or thickened pleural line
Sub-pleural consolidation
Small or no pleural effusions (large effusions are uncommon in COVID-19)
Dense consolidation with air bronchograms in more severe disease

Lung ultrasound can identify features strongly supporting a diagnosis, map progression of disease and most importantly assess for alternative diagnoses^[4] (e.g. pneumothorax, pleural effusions).

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References:

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