Development of a COVID-19 Point-of-Care Ultrasound Protocol

To the Editor:

As reported in recent American Society of Echocardiography statements by Kirkpatrick et al. ¹ and Johri et al.,² point-of-care ultrasound (POCUS) is playing an increasingly important role in the diagnosis of cardiovascular pathology, including the assessment of myocardial injury in coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 infection. Buonsenso et al. ³ in another publication suggested that lung ultrasound could replace stethoscopes in order to reduce the risk for exposure. Although the American Society of Echocardiography statement on POCUS use during the COVID-19 pandemic provides a list of findings and indications related to different POCUS views, it does not provide specific instructions for a systematic imaging protocol.¹ In this correspondence, we share our experience with the development of a standard POCUS imaging protocol for patients with suspected or confirmed COVID-19. The goal of this protocol was to facilitate appropriate POCUS use by providing a reference that would allow the scanning and interpretation of images in a consistent and systematic fashion.

The first confirmed case of COVID-19 in the United States took place in January 2020 in the state of Washington, after which an outbreak ensued.⁴ To address the need for cardiovascular assessment in critically ill patients with COVID-19 while minimizing transmission risk, the University of Washington (UW) swiftly began the development of a POCUS protocol. A multidisciplinary team consisting of physicians from cardiology, critical care, hospitalist medicine, and anesthesiology was formed that oversaw the development of this protocol. A consensus was ultimately reached that six lung views and four cardiac views could provide essential information in patients with COVID-19 without placing undue burden on bedside providers (Figure 1 ). This protocol, along with standardized machine cleaning instructions, was distributed in all isolation units throughout the UW system. By using POCUS in patients with COVID-19, disease pathologies ranging from pneumonia and acute respiratory distress syndrome to systolic heart failure and acute myocardial injury could be identified and monitored, while minimizing personnel and equipment exposure and personal protective equipment use.

Figure 1.

Standard COVID-19 POCUS imaging protocol developed by the UW Cardiology and Sonography in Critical Care (SiCC) teams. IVC, Inferior vena cava; Ling., lingula; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.

In anticipation of a large burden of COVID-19 cases, UW acquired additional handheld ultrasound machines, some of which were provided free of charge by the manufacturers. Additionally, ultrasound simulators and mannequins were obtained to provide standardized training in image acquisition and interpretation for trainees.⁵ Images obtained using handheld ultrasound machines would be uploaded to the picture archiving and communication system for image archiving. These images would therefore be virtually available, including to the echocardiography laboratory, which could provide support and feedback for POCUS users and provide guidance for potential subsequent imaging.

Our efforts have been positively received by clinicians across the UW system, as reflected by increasing participation in simulator training and implementation of the POCUS protocol. Our goal is to fully use POCUS during the COVID-19 pandemic to deliver high-quality care while ensuring the safety of patients and health care workers. We hope to not only continue this collaboration among the various subspecialties but also report findings from the application of this protocol in the near future.