Utility of Lung Ultrasound in Decision-making to Prioritize Hospital Admission for COVID-19 Patients: A Developing Country Perspective.

BACKGROUND AND AIMS: In the midst of this pandemic, planning the prioritization of hospital admissions for patients affected with COVID-19 should be of prime concern, particularly in healthcare settings with limited resources. Thus, in this study, we aimed to develop a novel approach to triage COVID-19 patients and attempt to prioritize their hospital admission using Lung Ultrasonography (LUS). The efficacy of LUS in triaging suspected COVID-19 patients and assessing the severity of COVID-19 pneumonia was evaluated; the findings were then compared with those obtained by chest computed tomography (CT). METHODS: This multicenter, cross-sectional study comprised 243 COVID-19 patients who presented to the emergency department in 3 major university hospitals in Egypt. LUS was performed by an experienced emergency or chest physician, according to the local protocol of each hospital. Demographic, clinical, and laboratory data were then collected from each patient. Each patient was subjected to chest CT scans and LUS. RESULTS: The mean age of the 243 patients was 46.7 ± 10.4 years. Ground-glass opacity, subpleural consolidation, translobar consolidation, and crazy paving were reported in the chest CT scans of 54.3%, 15.2%, 11.1%, and 8.6% of the patients, respectively. B-line artifacts were observed in 81.1% of the patients (confluent pattern, 18.9%). The LUS findings completely coincided with the CT findings (Kappa agreement value, 0.77) in 197 patients (81.1%) and offered a diagnostic sensitivity of 74%, diagnostic specificity of 97.9%, positive predictive value of 90.2%, and negative predictive value of 93.6% for the COVID-19 patients. Following the addition of O2 saturation to the lung imaging findings, the ultrasound method was able to demonstrate 100% sensitivity and specificity in accurately differentiating between severe and non-severe lung diseases. CONCLUSION: LUS with oxygen saturation might prove to be effective in prioritizing the hospital admission of COVID-19 patients, particularly in healthcare settings with limited resources.

Serial ultrasonographic monitoring of diaphragmatic and mid-upper arm muscle thickness in mechanically ventilated respiratory patients: A single-center observational study.

INTRODUCTION: Muscle monitoring during mechanical ventilation (MV) is gaining great interest nowadays; however, a proper monitoring tool is not well-established yet. OBJECTIVES: To assess the role of ultrasound in muscle monitoring during MV in respiratory patients. METHODS: Eligible 68 mechanically ventilated patients were consecutively enrolled. Serial ultrasound measurements of diaphragmatic thickness at the end of inspiration (Tdi) and mid-upper arm (MUA) muscle thickness were recorded every other day till weaning. Before discharge, functional status score (FSS) was assessed. RESULTS: Tdi decreased in 72.1%, did not change in 13.2% and increased in 14.7% of the patients. MUA muscle thickness decreased in 47.17% and did not change in others. Significant correlation between Tdi and MUA muscle thickness change was found (r = 0.404, P = 0.001); however, MUA muscle thickness change could not predict Tdi change (B = 0.067, P = 0.059). Diaphragmatic and MUA thickness change showed significant negative correlation with ICU stay (r = -0.260, -0.647, P = 0.032, <0.001) and MV duration (r = -0.335, -0.596, P = 0.005, <0.001), respectively. Weaning failure was significantly higher among patients with decreased Tdi (64.28%) and FSS was significantly lower in those with decreased MUA muscle thickness. US measurements of Tdi and MUA muscle thickness showed excellent intra-observer (ICC = 0.996, 0.999, P < 0.001) and inter-observer agreement (ICC = 0.992, 0.998, P < 0.001), respectively. CONCLUSION: Sonographic muscle monitoring during MV is promising. Changes in the diaphragmatic thickness during MV are common and weakly related to those of peripheral muscles. Early decreased muscle thickness heralds poor weaning and functional outcome.

Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients.

AIM: To evaluate role of diaphragmatic thickening and excursion, assessed ultrasonographically, in predicting extubation outcome. METHODS: Fifty-four patients who successfully passed spontaneous breathing trial (SBT) were enrolled. They were assessed by ultrasound during SBT evaluating diaphragmatic excursion, diaphragmatic thickness (Tdi) at end inspiration, at end expiration and diaphragmatic thickness fraction (DTF%). Simultaneously traditional weaning parameters were recorded. Patients were followed up for 48h after extubation. RESULTS: Out of 54 included patients, 14 (25.9%) failed extubation. Diaphragmatic excursion, Tdi at end inspiration, at end expiration and DTF% were significantly higher in the successful group compared to those who failed extubation (p<0.05). Cutoff values of diaphragmatic measures associated with successful extubation were ≥10.5mm for diaphragmatic excursion, ≥21mm for Tdi at end inspiration, ≥10.5mm for Tdi at end expiration, ≥34.2% for DTF% giving 87.5%, 77.5%, 80% and 90% sensitivity respectively and 71.5%, 86.6%, 50% and 64.3% specificity respectively. Combining diaphragmatic excursion ≥10.5mm and Tdi at end inspiration ≥21mm decreased sensitivity to 64.9% but increased specificity to 100%. Rapid shallow breathing index (RSBI) <105 had 90% sensitivity but 18.7% specificity. CONCLUSION: Ultrasound evaluation of diaphragmatic excursion and thickness at end inspiration could be a good predictor of extubation outcome in patients who passed SBT. It is recommended to consider the use of these parameters with RSBI consequently to improve extubation outcome.

Brain natriuretic peptide as a predictor of weaning from mechanical ventilation in patients with respiratory illness.

BACKGROUND: Cardiovascular dysfunction has been reported as an important mechanism of weaning failure. Brain natriuretic peptide (BNP) is a sensitive and specific marker for cardiovascular dysfunction. OBJECTIVE: To determine the value of BNP levels measured at initiation and end of a 2h spontaneous breathing trial (SBT) as a predictor of successful weaning of mechanical ventilation in patients with respiratory illness. PATIENTS AND METHODS: Thirty consecutive patients ready for weaning were prospectively enrolled in this cross-sectional analytic study over a 6-month period. All patients had been on spontaneous mode of weaning for at least 2h. Tidal volume, respiratory rate, rapid shallow breathing index (RSBI), minute ventilation and PaO2/FiO2 were observed at initiation of SBT. BNP was measured at the initiation (BNP1) and at the end of SBT (BNP2). Weaning failure is defined as either the failure of SBT or the need for reintubation within 48 h following extubation. RESULTS: Out of the 30 included patients, 14 (46.6%) patients had failed weaning. PaCO2 and BNP2 were significantly higher in the patients with failed weaning as compared to those with successful weaning (P = 0.025, P = 0.031 respectively). However, BNP1 levels were not statistically significant between the 2 groups (P = 0.722). On multiple regression analysis, BNP% (percent change in the BNP level during the 2-h SBT) was the only predictor of weaning success. As compared to other weaning parameters, BNP% ≤ 14.9 had the best sensitivity, specificity, positive and negative predictive value. CONCLUSION: Measuring the percentage change in the BNP level during a SBT may be a good predictor of weaning success from mechanical ventilation in respiratory patients.

B-lines: Transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases.

OBJECTIVE: This prospective study was conducted to evaluate the value of sonographic B-lines (previously called "comet tail artifacts"), which are long, vertical, well-defined, hyperechoic, dynamic lines originating from the pleural line in assessment of interstitial lung diseases (ILD) and compare them with the findings of chest high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs). MATERIALS AND METHODS: Sixty-one patients with ILD underwent transthoracic lung ultrasound for assessment of the presence of B-lines and the distance between them. These findings were compared with that of chest HRCT (ground glass, reticular, nodular or honey combing) and PFT as forced vital capacity (FVC), total lung capacity (TLC), diffusion capacity for carbon monoxide (DLCO) and partial arterial oxygen pressure (PaO2). RESULTS: All patients had diffuse bilateral B-lines. The distance between each of the two adjacent B lines correlated with the severity of the disease on chest HRCT where B3 (the distance was 3 mm) correlated with ground glass opacity and B7 (the distance was 7 mm) correlated with extensive fibrosis and honey combing. Also, the distance between B-lines inversely correlated with FVC (r = -0.848, P < 0.001), TLC (r = -0.664, P < 0.001), DLCO (r = -0.817, P < 0.001) and PaO2 (r = -0.902, P < 0.001). CONCLUSION: B-lines that are lung Ultrasound signs seem to be useful in the assessment of ILD.

Evaluation of different combined regimens in the treatment of cholinergic urticaria.

BACKGROUND: : Cholinergic urticaria is uncommon and accounts for 10% of all young adults. To date, there is no effective therapy for cholinergic urticaria. OBJECTIVE: : To determine the therapeutic efficacy of different drug combinations in the treatment of cholinergic urticaria. PATIENTS AND METHODS: : The participants included in the study are in the age range of 16 to 29 years, with cholinergic urticaria of any duration as diagnosed by physicians. Patients were recruited from Asthma and Allergy Centers in Baghdad and Tikrit. The selected patients were divided randomly into 3 groups according to the treatment protocol. All patients completed screening before treatment. RESULTS: : The study indicated that cholinergic urticaria was completely controlled in 30.4% of patients (group A) receiving 4 mg of chlorpheniramine maleate, half hour before the exercise, plus chlordiazopoxide (5 mg) and clindium bromide (2.5 mg) tablets, 3 times daily. However, cure rate was higher (83.1%) in patients (group B) receiving 4 mg of chlorpheniramine maleate (histadine), 3 times daily, plus 25 mg of maprotiline HCl (ludiomil), once daily at night. Furthermore, the complete cure rate was 85.4% in patients (group C) receiving 4 mg of chlorpheniramine maleate (histadine)3 times daily, plus 200 mg of cimetidine (tagadine), 3 times daily. The frequency of relapse was higher in group A (89%) as compared with group B (68.4%) and group C (23.5%) (P < 0.0001). CONCLUSIONS: : Combination of H1 and H2 antagonists was more effective based on complete control of cholinergic urticaria with lower relapsing rate. However, a future placebo-controlled clinical trial taking in consideration higher H1 antagonists than we used is warranted.