Lung Ultrasound in COVID 19 Pandemic. Recommendations

Elmo Fabiano Monteiro Pereira Jr., Marcos de Carvalho Bethlem, Ana Luisa Silveira Vieira, Marcus Gomes Bastos, José Muniz Pazeli Jr


Until now, we had 3.551 suspected cases of coronavírus related disease SARS-CoV-2 (COVID-19) in Brazil, with 428 confirmed cases and 1.841 cases discarted. 11.278 remain undiagnosed[1].

In the initial phase, the use of the molecular test can have a sensibility of 60 to 70%. CT Scan seems to be the most sensitive tool[2].  The availability of CT scan devices in Brazil is limited[3].

The main finding related to COVID-19 is the presence of peripheral ground glass opacities [4,5].

The peripheral finding in CT scan can be visualized by lung ultrasound, with high concordance[6]

Literature Review

A case presentation from Rome, Italy ,of a COVID-19 patient, described the presence of an irregular pleural line, subpleural microconsolidations and fused, coalescent B lines.

The Rouby protocol was used to perform the examination (superior/inferior, anterior/lateral/posterior, right/left windows)8. (Fig 1).

Lung windows, Rouby’s protocol

A 20 cases serie from Xiam, China, also using Rouby protocol, shows  that 75% of patients presented ultrasound findings in postero-inferior windows.

Coalescent B lines, pleural irregularities, microconsolidation and consolidations with air bronchogram were demonstrated.[9] .

Another 20 cases serie, from Changsha and Pekin, China, evidenced pleural irregularities, several B lines patterns (focal, multifocal, confluent), consolidations with different patterns (small and multifocal, lobar with air bronchogram and A lines during recuperation  phase. Pleural effusion was an infrequent finding[10].

Finally, a 12 cases serie of Piacenza, Italy, shows a diffuse B pattern, with preserved areas.

Three patients presented posterior microconsolidations[11].

The oblique lung windows increase  the  pleural  visualization  area (except L5 and R5 , where need to be longitudinal, according to Gargani and Volpicelli12 (Fig. 2).

Longitudinal approach vs oblique in pleural visualization


  • Lung  ultrasound must be used for  severity  staging  and monitoring  critically ill patients with COVID-19. (STRONG Recommendation ).
  • We must use the Rouby’s protocol with oblique approach for the visualization and registration of the lung windows to perform the examination. (STRONG Recommendation).
  • Routine lung ultrasound examination should not be used for tracking and diagnosis of COVID-19. (STRONG Recommendation).


1. #COVID-19-brazil
2. 10.1148/radiol.2020200642 (doi)
3. 10.5935/0103-507x.20190033 (doi)
4. 10.1016/S1473-3099(20)30086-4 (doi)
5. 10.1056/NEJMoa2002032 (doi)
6. 10.1007/s00134-019-05725-8 (doi)

7. 10.26355/eurrev_202003_20549 (doi)
8. 10.1097/CCM.0b013e31824e68ae (doi)
9. 10.2139/ssrn.3544750 (doi)
10. 10.1007/s00134-020-05996-6 (doi)
11. 10.1148/radiol.2020200847 (doi)
12. 10.1186/1476-7120-12-25 (doi)

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