Egyptian Consensus on the Role of Lung Ultrasonography During the Coronavirus Disease 2019 Pandemic

Figures & data

Table 1 Summary of the Statements and Their Percentage of Agreement

No.	Covered Area	Statement	Percentage of Agreement	Level of Agreement
1	Assessment of COVID-19 severity is essential	Objective staging of the disease severity and evaluation of the course of infection help make proper treatment choices and improve prognosis. Consequently, this would reflect on the reduction of the chain of transmission and the overall morbidity and mortality from COVID-19.	91	A
2	Indication of lung imaging	Indication of lung imaging	86	B
		Because respiratory dysfunction is the main cause of morbidity and mortality in patients with COVID-19, lung imaging is considered a key tool for assessing the disease. Lung imaging is indicated for medical triage of patients suspected to have COVID-19, who present with moderate to severe disease. It helps determine the proper site of patient care: either home, hospital ward, or intensive care unit. Imaging may also be advised to assess disease progression during the follow-up of confirmed COVID-19 cases.
3	Advantage of lung HRCT during the COVID-19 pandemic	Chest CT is more sensitive and effective in triaging or following up patients with COVID-19 than chest X-ray.	100	A
		During the COVID-19 pandemic, the typical HRCT pattern consists of multiple ground-glass opacities (GGOs) mainly in the peripheral and basal lung regions. GGOs may be combined with other features, such as pulmonary consolidation, crazy paving, halo signs, basal reticulations, and vascular enlargement.
4	Limitations of chest CT during the COVID-19 pandemic	The limitations of chest CT during the COVID-19 pandemic in developing countries include burden, cost, unavailability, infection, repeating, and exposure to ionizing radiation, among others.	94	A
5	LUS can overcome CT limitations	LUS is a rapid bedside test that does not involve exposure to ionizing radiation, has a lower cost, and can be repeated (whenever indicated) without significant risks to the patient.	90	A
6	LUS findings of a normal aerated lung	6 a: A normal aerated lung is characterized by the presence of the following:	94	A
		A bright, thin, smooth pleural line between two ribs A-lines, which are repeated horizontal artifacts parallel to the pleural line Normal lung sliding
	LUS findings of an abnormal aerated lung	6 b: A bad aerated lung is characterized by multiple B-lines and an irregular pleural line with or without subpleural consolidative patterns on LUS.	100	A
		Moderate loss of lung aeration (interstitial syndrome): multiple (>3) spaced B-lines. It corresponds to a “ground-glass area” on lung HRCT. Severe aeration loss (diffuse alveolar edema): diffuse coalescent B-lines occupying most intercostal space. Complete aeration loss (Lung consolidation) and the presence of a tissue pattern characterized by dynamic air bronchograms.
7	LUS findings in COVID-19 pneumonia	During the COVID-19 pandemic, the presence of multiple (≥3) B-lines with or without subpleural consolidations distributed bilaterally, peripherally, or basally in patches with spared areas on LUS is highly suggestive of COVID-19 pneumonia in clinically suspected patients.	97	A
8	LUS score in COVID-19	LUS score based on the examination of 12 standard regions can be used to assess lung aeration changes and follow up disease progression.	97	A
9	Effectiveness of LUS performed by a well-trained physician or expert	Bedside LUS, performed by a well-trained physician or expert, is a useful tool in screening and monitoring suspected or confirmed COVID-19 cases, with an acceptable accuracy rate.	97	A
10	Infection control is paramount	Infection control is paramount.	94	A
		National and local guidelines on PPE usage should be followed. The probe should be disinfected before and after patient examination to avoid nosocomial infection and cross-contamination.

Notes: A: ≥90%. B: 80% to <90%.

Abbreviations: HRCT, high-resolution computerized tomography; LUS, lung ultrasonography; PPE, personal protective equipment.

Figure 1 Lung ultrasonography of a mild COVID-19 case with a normal aerated lung. (A) A bright, thin, smooth pleural line between the two ribs and A-lines are seen as horizontal repetitions of the pleural line between the shadows of the two ribs. (B) Normal lung sliding (seashore sign using M mode). T: T lines are vertical lines, in time with cardiac pulsation, running from the pleural line to the bottom of the image.

Figure 2 LUS of a patient with COVID-19 with a partially de-aerated lung showing the absence of A-lines, bilateral peripheral multiple spaced (B) B-lines (A), and thick and/or irregular pleural line, subpleural consolidation, and confluent B-line (B).

Figure 3 B-lines with patchy distribution and spared areas. Left: Speared area with A-pattern; smooth pleural line and A-lines. Right: B-pattern; irregular pleural line and multiple spaced B-lines (poor lung aeration).

Table 2 Different Protocols for the Lung Ultrasound Scoring System

Scoring Protocol Reference	Number of Lung Zones Examined	Items Evaluated	Scoring (of Each Lung Zone)	Total Score
LUS score (LUSS) Coalescence score (cLUSS)^Citation91,Citation92	12	● A-lines ● B-lines (number and coalescence) ● Subpleural consolidations ● Consolidation	0: normal pattern (A-lines or insignificant B-lines) (pattern A) 1: significant B-lines (≥3 per rib space) (pattern B1) 2: coalescent B-lines with or without small consolidations (pattern B2) 3: consolidation (pattern C)	36
Modified LUSS (mLUSS) Quantitative score (qLUSS)^Citation93	12	● A-lines ● Pleural involvement > 50% or ≤ 50% ● B-lines ● Subpleural consolidations ● Consolidation	0: A-lines – max 2 B-lines 1: artifacts occupying ≤ 50% of the pleura 2: artifacts occupying > 50% of the pleura 3: consolidation (Artifacts : well-spaced B-lines if ≥ 3, coalescent B-lines, subpleural consolidations)	36
COVID-19 LUS in the ED (CLUE) protocol^Citation73	12	● A-lines ● B-lines (number and confluence) ● Pleural line (thickness and irregularity) ● Subpleural consolidations ● Consolidation ● Severity index grading and disposition  planning from the emergency department	0: A-lines, 1 or 2 B-lines, smooth thin pleural line 1: > 2 B-lines but discrete, irregular/thickened pleura 2: confluent B-lines, subpleural consolidations (height < 1 cm) 3: lung consolidation (height > 1 cm), +/− air bronchogram +/− vascularity	36
Composite LUS^Citation94	12	B-lines/consolidation quantitative score (score 0–3) + Pleural abnormalities quantitative score (score 0–2).	B-lines/consolidation quantitative score: 0: well-spaced B-lines <3 1: well-spaced B-lines ≥3 2: multiple coalescent B-lines 3: lung consolidation The pleural line quantitative score: 0: normal 1: irregular pleural line 2: blurred pleural line	60
Modified lung ultrasound (MLUS) scoring (modified based on the ILD Buda scoring system)^Citation64	10	Pleural line involvement (0–3) + Lung parenchymal involvement (0–4) + Complications (0,4)	Pleural line involvement 0: Normal pleura 1: thickening (≥0.5 mm) or irregular 2: blurred 3: discontinuous, fragmented Lung parenchymal involvement 0: no B-line 1: presence of B-line ≤3 2: presence of B-lines ≥4 or partially merged 3: presence of B-line fully integrated (white lung or waterfall sign) 4: presence of pulmonary consolidation or subpleural lesion Complications 0: none 4: am line (pulmonary balloon); 4: pneumothorax or empyema 4: pleural effusion	110
LU score^Citation95	14	● A-lines ● B-lines (coalescence and distribution) ● Consolidations ● Pleural line (irregularity and fragmentation)	0: A-lines with continuous and regular pleural line 1: visible B-lines and irregularities in the pleural line 2: discontinuous pleural line with dark areas under the pleura (consolidations) with associations of B-lines 3: coalescent B-lines with “white lung” aspect, dense and widely distributed, with or without consolidations.	42
B-line score (estimate accumulation of extravascular lung water [EVLW])^Citation96	Evaluate each intercostal space (from second to fifth) anteriorly and laterally	B-lines (number)	0:  ≤ 5 B-lines (absent EVLW) 1: 6–15 B-lines (mild EVLW) 2: 16–3 B-lines (moderate EVLW) 3: > 30 B-lines (severe EVLW)
LUS for the early diagnosis of COVID‑19 pneumonia: an international multicenter study [1] Volpicelli, G. et al, Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study. Intensive care medicine, 2021. 47 (4): p. 444–454	5 scans Scan 1 (anterior chest) Scan 2 (lateral chest): 4–5 lateral intercostal spaces [scan performed longitudinally] Scan 3 (lateral chest): costophrenic angles [scan performed in oblique] Scan 4 (posterior chest): 4–5 posterior intercostal spaces between scapula and spine line [scan performed longitudinally] Scan 5 (posterior chest): 3–4 posterior intercostal spaces below the inferior margin of the scapula [scan performed in oblique]	LUS probability patterns ● A-lines ● B-lines (coalescence and distribution) ● Consolidations ● Pleural line ● Pleural effusion + Clinical phenotypes 1.mild phenotype 2.severe phenotype mixed phenotype	LUS probability patterns 1.Low probability (Low LUS): a normal or near-normal LUS pattern (bilateral A-lines with lung sliding and without significant B-lines) 2.High probability (High LUS): (typical pattern) bilateral and multifocal clusters of separated or coalescent B-lines, multifocal peripheral consolidations, regular and irregular pleural line, with or without large consolidations. These clusters appear patchy distribution, abruptly alternating with normal A-lines patterns (“spared areas”). 3.Intermediate probability (IntLUS): (less typical pattern) unilateral isolated clusters of B-lines or focal multiple B-lines, with or without small peripheral consolidations. 4.Alternative probability (AltLUS): (more consistent with an alternative diagnosis) such as →an isolated large consolidation with dynamic air bronchograms (suggesting bacterial pneumonia) or without bronchograms (suggesting obstructive atelectasis), →a large pleural effusion, diffuse homogeneously distributed B-lines (suggesting cardiogenic edema or diffuse fibrosis).

Figure 4 The lung ultrasonography score, based on the examination of 12 regions of interest (six on the right side and six on the left side), has been proposed to assess lung aeration changes caused by different pathological lung conditions. PSL: AAL: PAL: PVL.

Figure 5 LUS score (LUSS) according to sonographic pattern: For each region, we allocated points, ranging from 0 to 3, according to the poorest ultrasound pattern observed. 0 = normal aeration, 1 = interstitial syndrome, 2 = alveolar edema, and 3 = consolidation. The final LUSS is the sum of the points in all 12 regions, which ranges from 0 to 36. Accordingly, the grading the disease severity index can be estimated: mild (score <5), moderate (<15), and severe (>15).

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