02 Apr Under pressure, one Italian doctor triages by Ultrasound. Article
Liam Davenport. March 24, 2020
Patients have been arriving at the emergency department of the University Hospital San Luigi Gonzaga, in Turin, Italy, one after another after another.
At first, physicians thought advanced age was a good predictor of which cases might go downhill fast. They were wrong. “We intubated a woman who was 38 years old,” says Giovanni Volpicelli, MD. “We see otherwise healthy patients with acute symptoms of pneumonia due to the virus.” And the more patients they see, he says, “the more we see that anyone over 30 is affected.”
Because they couldn’t use age nor underlying condition to predict which patients would develop severe COVID-19-associated pneumonia, they needed a new approach.
That’s what led Volpicelli, a leading expert in treating patients on the coronavirus front lines, to develop a method that can separate out the lethal from the less dangerous cases: triage via ultrasound.
The technique has not yet been peer reviewed, but Volpicelli and his colleagues are now convinced that lung ultrasounds should be done at the bedside for all patients suspected of infection with the novel coronavirus. Even people with mild symptoms, he says, could harbor lung disease that quickly leads to severe pneumonia and respiratory failure.
In his experience, ultrasound assessment effectively separates those who need to be admitted from those who can be sent home to convalesce under quarantine.
Building a Triage Protocol
He and his team have developed a standard approach that starts with a nurse classifying patients based on whether they have fever, cough, or labored breathing — just one of those symptoms is enough to prompt suspicion and the patient is moved into isolation. Then, Volpicelli says, after an examination, “the first thing we do is lung ultrasound.”
That’s because, as the pandemic tore through his city, he began to see that so many patients presented with a negative chest X-ray but a lung ultrasound that was positive for interstitial pneumonia.
Ultrasounds, he discovered, were very useful to both screen for and diagnose someone with the disease. “Only by using a test that can assess the situation of the lung at the beginning of the disease do you become aware that pneumonia can also be present…even in patients with mild or almost no symptoms — just a little bit of fever,” Volpicelli says.
More often than not, an ultrasound is negative and emergency department staff continue their diagnostics. They swab nasal passages for testing with RT-polymerase chain reaction (rRT-PCR), then they send the patient home to wait for test results in isolation.
The peripheral finding in CT scan can be visualized by lung ultrasound, with high concordance