A Simplified Point-of-Care Lung Ultrasound Protocol to Detect Coronavirus Disease 2019 in Inpatients: A Prospective Observational Study
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Abstract
Objectives
To assess the diagnostic performance of lung point-of-care ultrasound (POCUS) compared to either a positive nucleic acid test (NAT) or a COVID-19-typical pattern on computed tomography (CT) and to evaluate opportunities to simplify a POCUS algorithm.
Methods
Hospital-admitted adult inpatients with (1) either confirmed or suspected COVID-19 and (2) a completed or ordered CT within the preceding 24 hours were recruited. Twelve lung zones were scanned with a handheld POCUS machine. POCUS, CT, and X-ray (CXR) images were reviewed independently by blinded experts. A simplified POCUS algorithm was developed via machine learning.
Results
Of 79 enrolled subjects, 26.6% had a positive NAT and 31.6% had a CT typical for COVID-19. The receiver operator curve (ROC) for a 12-zone POCUS protocol had an area under the curve (AUC) of 0.787 for positive NAT and 0.820 for typical CT. A simplified four-zone protocol had an AUC of 0.862 for typical CT and 0.862 for positive NAT. CT had an AUC of 0.815 for positive NAT; CXR had AUCs of 0.793 for positive NAT and 0.733 for typical CT. Performance of the four-zone protocol was superior to CXR for positive NAT (p=0.0471). Using a two-point cutoff system, the four-zone POCUS protocol had a sensitivity of 0.920 and 0.904 compared to CT and NAT, respectively, at the lower cutoff; it had a specificity of 0.926 and 0.948 at the higher cutoff, respectively.
Conclusion
POCUS outperformed CXR to predict positive NAT. POCUS could potentially replace other chest imaging for persons under investigation for COVID-19.
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SciScore for 10.1101/2021.04.19.21254974: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: The protocol was approved in writing by the local Institutional Review Board.
Consent: Data Collection: After obtaining assent from the treating team and verbal consent from the patient or proxy, a research physician scanned 12 lung zones (Figure 1), similar to prior protocols.Sex as a biological variable not detected. Randomization not detected. Blinding All scanners were blinded to CT results, though not to NAT results (positive results are prominently displayed in the chart), at the time of scanning. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share …
SciScore for 10.1101/2021.04.19.21254974: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: The protocol was approved in writing by the local Institutional Review Board.
Consent: Data Collection: After obtaining assent from the treating team and verbal consent from the patient or proxy, a research physician scanned 12 lung zones (Figure 1), similar to prior protocols.Sex as a biological variable not detected. Randomization not detected. Blinding All scanners were blinded to CT results, though not to NAT results (positive results are prominently displayed in the chart), at the time of scanning. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Our study was subject to several limitations. First, this was a single-center study, using a convenience sample of inpatients based on scanning physician availability. However, there have been relatively few prospective studies to date, particularly multi-center studies. Validation studies performed at other centers are warranted and welcome. Second, our study examined only inpatients (mostly from the ward, with a small number of ICU patients); it is unknown whether this scanning protocol would yield similar results for outpatients or ED patients. Third, the relatively high incidence of COVID-19 (26.6%) could lead to a spectrum effect. However, this incidence is lower than some other studies, and our sample did include many patients with low-suspicion CXR and CT results. Fourth, we note that, although many of our patients were quite sick, none of them were proned at the time of exam. It is unknown whether our protocol would have the same accuracy in proned patients. However, it is rare to prone a ward patient without a confirmed diagnosis of COVID-19. Fifth, although scanning physicians were blinded to CT results, they were not blinded to NAT status (positive COVID status is displayed prominently in our hospital electronic record); it is possible that sampling bias of the lung zones was introduced. However, COVID-positive and PUI patients had similar POCUS scan times. Sixth, none of the patients with an initial negative NAT subsequently had a positive NAT. However, this was a...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
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