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2. is there any way to find signs to bad pronostic in patiens making US before worst situations, maybe at the same time that diagnosis and first Rx ?

Vicki Noble
Gio is going to go through the ultrasound findings – the prognostic value is still somewhat conflicted as we have had people with quite significant findings who recover completely but there is some trending that will be helpful? Cardiac depression is one worrisome sign

3. Role of LUS in Emergency department ?

Gio is going to talk sbout how ultrasound is more helpful for screening in the ED.   and safe 🙂

4.which references show real 50% asymptomatic (never symptoms in the follow-up)?

this is epidemiological data provided by world health organization – of course dont take this as gospel as it depends on testing data and reporting world wide which as we know is not perfect.   but i think we can appreciate that the asymptomatic population is high enough to faciliate the spread

5. how did you protect your us sistems ?

viral wipes, contact precautions with covers and barriers    there is a nice article about this from American College of Emergency Physicians. and on twitter early on there were lots of suggestions and protocols as well

6. how to scan entubated patiebt in pron position ?

good question.   you need help :).   same in vented patients who arent prone.  you need someone to help you rotate them to scan.  but in some respects the screen and monitoring doesnt need to be the full scan.  what paul is saying now

7. I don’t know why is useful at emergencie department, because you hava the Chest X Ray, and if a patient has a pneumonia, specially bilateral, should be admitted …

because chest xray cant see as much. you have to have consolidation.  cant tell you if pleura or interstitium is sick. also you cant monitor.  chest xray once bad does not change hour to hour.  but ultrasound does

but again depends on your setting.  if you are a one man show but have 24 7 minute techonologist who can do chest xrays at the drop of a hat?   but in the USA it is faster for me to do my own ultrasound

8. In the ED, once you see a patient with B2 lines in all anterior and lateral chest zones, and clinically suggestive of Covid 19, unless in clinical research,  I don’t find it very useful to scan the complete dorsal areas. Would you agree?

agree unless they are going to ICU and they are going to monitor response to high flow O2 or prone positioning.   they can use those clips to see if they are improving from baseline

9. Hello. What types of ultrasound machine do you use in your hospital? Mobile? Portable? or Console? Is there any discrepancy of accuracy among machines? (In my hospital, I only have a big console machine)

laptop machines are easier for maneurvarbility.   the hand held obviously are also very convenient. for ICU or ED the consule machines are more challenging unless you have a dedicated ultrasound room you can use.   all machines have their pros and cons but for lung you just have to get used to your machine and settings because you are learning artifacts

10. it is important to know it is B7 or B3 ?

the more confluent the lines the more sick the lung.  this is the only reason it matters

11. has your group done anything with using lung POCUS to help diagnose Covid (e.g., if PCR is negative, but patient is still high risk; or if you don’t have access to rapid PCR… having very typical findings like the Light beam could be very suggestive). we’ve done a study in this regard at MGH, and would love to collaborate/validate our findings, if you guys (or anyone else) is interested!

he is going to get to scoring systems soon ….

12. The role of color doppler in assessement COVID 19 subpleural consolidation ?

not known yet – not part of standard assessment

13. do you think those consolidation might be as a result of embolic consolidation..?

oh that is a tough question.  you mean like thrombotic infarct?   it could be but if it is really large without a lot of inflammatory changes around it is much more likely to be bacterial

14. When do you order a CT exam? Is carzy paving pattern more specific of COVID pneumonia than ‘light beam’, subpleural consolidations and irregular pleural line, individually or collectively?

CT scans at baseline to set basal disease – otherwise lung for monitoring?

15. fundamentally in subpleural consolidations, are they from embolic event..? how to differenciate them..?

this is a hard question.  but I think emoblic events are more focal.   viral subpleural consolidations have surrounding pleural changes and blines.  embolic events are usually more discrete

16. Hello to everyone, thanks for the lectures. How can be distinguish between coalescent B lines and lung hepatization?

you will see bronchograms in hepatization. blines dont see tissue

17. Are you regularly admitting/observing patients who you would otherwise discharge (relatively well or negative CXR) for ultrasonographically evident pneumonia? Does days of illness affect your decision in this regard?

this is really great question.   i have found that we have patients with negative chest xray, normal oxygenation and lots of lung findings.   we have a home monitoring program for home O2 in the USA and this patient always went home on monitoring – not sick enough for admission but has lots of lung findings that are hidden. and some of those patients did fine and recovered (see @yaletung twitter).  some though got worse and their lung findings worsened with totally normal lung ultrasound i didnt worry ultrasound findings – and correlating with ventilation settings