Lung Ultrasound in Patients with Coronavirus COVID-19 Disease

White paper Lung Ultrasound in Patients with Coronavirus COVID-19 Disease Dirk-André Clevert, MD Professor of Radiology Section Chief of the Interdisciplinary Ultrasound Center at the Department of Clinical Radiology University of Munich Hospitals, Grosshadern Campus HOOD05162003083241 10 April 2020 siemens-healthineers.com/ultrasound SIEMENS Healthineers White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease Lung Ultrasound in Patients with Coronavirus COVID-19 Disease Dirk-André Clevert, MD Professor of Radiology Section Chief of the Interdisciplinary Ultrasound Center at the Department of Clinical Radiology University of Munich Hospitals, Grosshadern Campus Contents Introduction 3 Basics of lung ultrasound 5 Artifacts 7 Transducer selection and settings 11 Image fusion 13 Examination procedure 14 Basic lung exam 15 Summary of Coronavirus COVID-19 examination and follow-up 21 References 24 2 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper Introduction According to the Center for Systems Science and evaluation, but transportation of patients outside the Engineering (CSSE) at Johns Hopkins University (JHU), ICU is difficult and potentially harmful [7]. HR-CT scans Coronavirus COVID-19 disease increased daily worldwide. expose patients to doses of radiation and should be On March 20, 2020 at 8 a.m. European time, there reserved for specific situations (e.g., the evaluation of were 81,199 officially reported confirmed COVID-19 mediastinal pathologies and confirmation of pulmonary cases in China, 163,324 cases in the rest of the world. embolism) [8–10]. Bedside chest X-ray (CXR) is still The number of Coronavirus cases increased rapidly in considered the standard of care for many diagnostic the United States of America and Europe [1]. applications in the ICU. However, this imaging technique The World Health Organization (WHO) announced has important methodological limitations and often a pandemic infection with an unknown species of yields low accuracy [11]. Furthermore, it is important to coronavirus called SARS-CoV-2 [2]. consider radioprotection issues. As lung abnormalities may develop before clinical manifestations and nucleic According to Wujtewicz, spreading mainly through acid detection, experts have recommended early the droplet route, the virus causes mild symptoms in chest CT for screening suspected patients [12]. The the majority of cases, the most common being: fever high contagiousness of SARS-CoV-2 and the risk of (80%), dry cough (56%), fatigue (22%) and muscle pain transporting unstable patients with hypoxemia and (7%); less common symptoms include a sore throat, hemodynamic failure, make chest CT a limited option a runny nose, diarrhea, hemoptysis and chills [3]. for the patient with suspected or established COVID-19 A life-threatening complication of SARS-CoV-2 infection [12]. Lung ultrasonography (LUS) gives results that are is an acute respiratory distress syndrome (ARDS), similar to HR-CT and superior to standard chest CXR for which occurs more often in older adults, those with evaluation of pneumonia and/or ARDS with the added immune disorders and co-morbidities. Severe forms advantage of ease of use at point of care, repeatability, of the infection, being an indication for treatment in absence of radiation exposure, and low cost [12–13]. the intensive care unit (ICU), comprise of acute lung Cumulative ionizing radiation has known harmful inflammation, ARDS, sepsis and septic shock [3]. effects. [14] The use of bedside ultrasound could reduce Critically ill patients frequently need thoracic imaging standard CXR and HR-CT in the ICU [5–6]. due to the constant evolution of their clinical conditions [4]. A key part of monitoring critical patients in the ICU is thoracic ultrasound, as it allows the intensivist to examine the lung and pleural space [5–6]. High- resolution computed tomography (HR-CT) scans remains the gold standard imaging technique for thoracic siemens-healthineers.com/ultrasound 3 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 18L6 Sequoia GENERAL1 TIB:0.27 TIC:0.81 TIS:0.27 MI:1.03 95% 2D H Mid Skin/ 0dB/DR65 subcutaneous Pectoris Intercoastal tissue muscles Rib muscles Pleura Internal thoracic artery Figure 1: Anatomical basics of the superficial chest wall structures and lung using the panoramic view. 18L6 H Sequoia *GENERAL1 TIB:0.42 TIC:0.93 TIS:0.42 MI:0.76 20fps 95% 2D Mid 0dB/DR65 Mid OdB/ General cm/s PRF 1190 3cm Figure 2: Anatomical basics of the chest wall structures and the internal thoracic artery using the color Doppler examination. 4 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 18L6 H Sequoia General TIB:0.34 TIC:0.93 TIS:0.34 MI:0.98 46fps 95% 2D H High 2dB/DR65 3cm Figure 3: Dynamic examination of the intercostal muscles. Relaxation of the muscle during expiration. Basics of lung ultrasound examinations Thorax and lung sonography (LUS) have gained Acute dyspnoea is a common leading symptom in the importance in daily routine [15–20] which is especially ER and ICU. The range of possible differential diagnoses true in the setting of point-of-care ultrasound (POCUS) is wide, so after the patient history and physical and vital [21] (Figure 1). signs are taken, an urgent portable ultrasound should The first sonographic examinations of the lung were be performed. Focused lung sonography (LUS) plays performed more than 50 years ago [22–23]. Except for a dominant role in emergency sonography alongside echocardiography used in cardiology and sonography focused sonography of the abdomen, heart and lung used in obstetrics, ultrasound, in general, was a tool for (Figures 3–4). radiologists, and the lung was not considered suitable Although recommendations exist for elective chest for this imaging technology [24–26]. Since 1991, sonography [28–29] and emergency lung sonography intensivists have been using whole-body ultrasound [15], point of care lung sonography has not yet been to search for free fluid, vascular access and lung widely used in daily practice [30]. Compared to clinical ultrasound [27] (Figure 2). examination and chest X-ray (CXR), lung sonography siemens-healthineers.com/ultrasound 5 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 18L6 H Sequoia *GENERAL1 TIB:0.30 TIC:0.56 TIS:0.30 MI:0.59 77fps 95% 2D Mid 0dB/DR65 3cm Figure 4: Dynamic examination of the intercostal muscles. Contraction of the muscle during inspiration. shows excellent diagnostic accuracy in diagnosing Healthy lung tissue is composed primarily of air which pleural effusion, pneumothorax, pulmonary venous explains why it is not routinely visualized. The air in the congestion and consolidation [31–33]. lung scatters and impedes the transmission of sound In the diagnosis of lung pathologies, we often use waves. There is a huge gap between the acoustic ultrasound artifacts, arising from the chest wall and characteristics of soft tissues and the lung. The surface pleural surface, as an interpretation. In order to of the lung is a strong reflector of ultrasound waves understand the relevant normal anatomy, we will and thus creates several reverberation artifacts. These summarize the various patterns one may encounter artifacts contain valuable information and correlate when performing lung sonography. with the current lung pathophysiology. 6 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 12L3 Lung Tx Power 100% MI 0.74 TIS 0.6 TIB 0.6 SC 2 DTCE Med Dyn R 62 dB 6.2 MHZ 0 dB 23 fps A-lines 6 cm Figure 5: Ultrasound image demonstrating A-lines using a linear transducer. The A-lines are the bright horizontal lines deep to the pleural line. A-lines are a classic reverberation artifact. Artifacts In lung sonography we essentially interpret artifacts and back and forth, between the transducer and lung use their appearance for diagnostic purposes. There are surface. A-lines are parallel horizontal repetition lines two predominant artifactual patterns that a clinician of the pleura in the ultrasound image. Due to the fact may observe, and these have been termed “A-lines” and that this is a classic reverberation artifact, the distance “B-lines” [34]. from the skin to the pleural line equals the distance A-lines from the pleural line to the first A-line, the first A-line to the second A-line, and so forth (Figures 5–7). A-lines are reverberation artifacts caused by oscillating The A-line is created by an intact “dry” lung parenchyma sound waves. The ultrasound waves are reflected containing air combined with normal lung sliding. strongly by this tissue and the air interface and When sliding lung is absent, it is strongly suggestive reverberate [35–36]. The ultrasound waves bounce of pneumothorax [37]. siemens-healthineers.com/ultrasound 7 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 5C1 H Sequoia GENERAL 1 TIB:0.42 TIC:1.96 TIS:0.42 MI:1.39 28fps 98% 2D H Mid -2dB/DR60 A-lines 6 cm Figure 6: Ultrasound image demonstrating A-lines using a curved transducer. The A-lines are the bright horizontal lines deep to the pleural line. A-lines are a classic reverberation artefact. The distance from the skin to the pleural line equals the distance from the pleural line to the first A-line. Sequoia 5C1 *GENERAL1 TIB:1.16 TIC:1.64 TIS:0.42 MI: 1.39 40fps 98% 2D H Mid -2dB/DR60 M 0dB/DR55 6cm A-lines Figure 7: Ultrasound image demonstrating A-lines using a curved transducer. The A-lines are clearly visible on the M-mode as bright white lines. 8 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 18L6 H Sequoia GENERAL 1 TIB:0.30 TIC:0.56 TIS:0.30 MI:0.59 77fps 95% 2D Mid 0dB/DR65 3cm Comet-tail artifacts Figure 8: Ultrasound image demonstrating comet-tail artifacts. The artifact originates at the pleura but fades. B-lines areas [37]. These lines indicate accumulation of fluid in the pulmonary interstitial space (“lung rockets”) or alveoli The “comet-tail” ultrasonographic sign was first described (“ground glass”). Multiple B-lines are associated with by Ziskin and colleagues in 1982 when an intrahepatic pulmonary edema of cardiogenic and noncardiogenic shotgun pellet was observed to create an artifact like or mixed origin. They occur when sound waves pass what is seen in lung comets [38]. B-lines are not to be through the superficial soft tissues and cross the pleural confused with normal comet-tail artifacts that originate line encountering a mixture of air and water. One or two at the pleura but fade before reaching the edge of the B-lines are not too concerning but when they increase in screen (Figure 8). number or spread out in one zone, they are an indication The B-lines are vertical, highly dynamic, hyperechoic of lung interstitial syndrome (Figures 9–10). artifacts originating from the pleura or consolidation siemens-healthineers.com/ultrasound 9 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 10L4 H Sequoia *ABD TIB:0.27 TIC:0.54 TIS:0.27 MI:0.81 116fps 95% 2D High 5dB/DR65 B-lines 4cm Figure 9: Examination of the lung using a linear transducer. B-lines are discrete vertical hyperechoic reverberation artifacts that arise from the pleural line and extend to the bottom of the screen without fading. These artifacts move synchronously with lung sliding. 5C1 Abd Tx Power 100% MI 0.91 TIS 0.8 TIB 0.8 Dyn R 63 dB THI 3.6 MHZ 0 dB 35 fps B-lines 13 cm Figure 10: Examination of the lung using a curved transducer. B-lines are seen arising from the pleural line and extending to the bottom of the screen without fading. 10 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper Pneumonia 10L4 H Sequoia ABD TIB:0.28 TIC:0.92 TIS:0.28 MI:1.37 49fps 95% 2D H Mid 0dB/DR65 4cm Pleural effusion Pleural thickening Consolidations 04:53 Figure 11: Pneumonia examination of the lung with a linear transducer. Ultrasound findings including pleural effusion, pleural thickening and consolidations with additional accompanying B-line artifacts are seen. Transducer selection and settings Lung ultrasonography often relies on analysis of artifacts, low-penetration, high-frequency and high-definition such as A and B-lines, which can be optimized by altering linear transducers may be preferable for identifying machine settings; the experienced operator adapts pneumothorax and examining the superficial anterior machine settings for optimal visualization of these structures (i.e. pleural line lung sliding) in both children artifacts [39]. Conventional ultrasound systems with and thin adults. Phased and microconvex transducers can a “real-time B-mode” technique are suitable for be used for a broad range of specific indications. Keep in preoperative and postoperative transthoracic ultrasound. mind that low-frequency transducers will provide more Several ultrasonography probes are used for lung depth penetration but will sacrifice some image quality; ultrasound (LUS), and each has specific advantages and high-frequency transducers will provide better resolution limitations. The choice generally depends on multiple but will sacrifice depth penetration [37]. In recent years, factors, including patient anatomy, size and age, the however, prospective studies using high-frequency linear, depth and nature of the visualized structures and low-frequency curvilinear and low-frequency sector the goals of the investigation. Low-frequency convex transducers have demonstrated that the performance transducers are more suitable for Bedside Lung and interpretation of lung sonography is not transducer- Ultrasonography (BLUE) because they can be used to specific [39]. We use an ultrasound system with a convex visualize the deep posterior-lateral structures and can (5–1 MHz), linear (10–4 MHz) or sector transducer reveal consolidation and pleural effusion [37]. However, (8–3 MHz) (Figure 11). siemens-healthineers.com/ultrasound 11 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 5C 1 H Sequoia Schallkopf 1 *ABD_Std Nadel Ausgesteckt TIS:0,46 MI:0,55 77B/Sek 2D Mitel 0dB/DB60 10cm Figure 12: COVID-19 pneumonia. Follow-up examination in the ICU using real-time image fusion technique with a curved transducer. Ultrasound findings including pleural thickening and consolidations of the lung in the side-by-side mode are detected. HR-CT showed ground glass opacity and reticular shadows under the pleura in the field of the right lung. The basic ultrasound units should be equipped with The advanced ultrasound systems should be equipped pulsed and color Doppler and M-mode to be able to with shear wave elastography imaging, contrast evaluate vessels and the vascularization of pathological enhanced ultrasound (CEUS) and image fusion. Most findings [40]. ultrasound manufacturers use technical processes for In addition to standard B-mode, the diagnostic value of image enhancement, such as Compound Imaging and ultrasound can be improved by using dynamic M-mode. Harmonic Imaging. The result of using these modes is With M-mode, a single vertical line of the ultrasound overall better image quality necessary for a conventional image is selected. The ultrasound signals of this line are examination, however, disabling these modes will result displayed over time in a separate diagram which allows in a clearer display of comet-tail artifacts or B-lines [35]. movements in the tissue to be represented as curves. To optimize the visualization of the pleural line, the Immobile structures appear as horizontal lines. When focal zone, image depth and overall gain should be M-mode is applied to the lung exam, the system displays adjusted [14]. a representation of tissue motion over time [35]. 12 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper Schallkopf 3 10L4 H Allgemein Nadel Ausgesteckt TIB:0,39 TIC:0,90 TIS:0,39 Sequoia MI:0,96 29B/Sek 95% 2D H Niedrig 0dB / DB65 8cm Figure 13: COVID-19 pneumonia. Follow-up examination in the ICU using real-time image fusion technique with a linear transducer. HR-CT showed large flaps of soft tissues and low-density shadows under the pleura in the posterior segment of upper lobe of the left lung, and a large air bronchogram sign confirmed by ultrasound using the image fusion technique. Image fusion For complicated lung pathologies, real-time ultrasound be viewed in a side-by-side mode or in an overlay mode image fusion with a HR-CT dataset can be performed in real-time [42] (Figures 12–13). with high-end ultrasound systems. This is especially useful for ill patients in the ICU, because pathologies During image fusion, it is still technically possible to could be monitored directly at the bedside. CT use all other image modes of the ultrasound system examinations could be minimized and the risk for such as color Doppler and CEUS. Using multiple image contamination due to less transportation of the patient techniques in real-time allows comprehensive imaging will also decrease. When performing ultrasound fusion, and characterization of the vascularization of lung there is additional hardware required that includes a pathologies [43]. Fusion imaging could help in the magnetic field generator and a position sensor. The detection and localization of lung lesions with low position sensor makes it possible to detect the position conspicuity on standard B-mode ultrasound. In of the transducer in the three-dimensional space. abdominal imaging and animal studies, image fusion Image fusion is possible with most imaging modalities is already being used on several organs [44–64]. including CT. DICOM (digital imaging and communication in medicine) datasets of HR-CT scans can be coregistered with the help of the ultrasound system software and can siemens-healthineers.com/ultrasound 13 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease PSL PSL AAL AAL PAL PAL Figure 14: Transducer positions for a lung ultrasound examination in the recumbent/supine patient. The abbreviated examination covers two BLUE points and the PLAPS (posterolateral alveolar and/or pleural syndrome) points on both sides (for the detailed description and how to localize BLUE and PLAPS points see [72]). Examination procedure Lung ultrasound is used in emergency and intensive anterior, lateral, and posterior regions of the left and care patients in supine (ventral thorax) and, depending right chest wall will be carefully examined [65]. on the clinic, in a sitting position (dorsal thorax). The exam should be performed in a systematic manner that Three “standard” lung points are usually described in investigates the entire anterolateral and posterior lung relation to the Bedside Lung Ultrasonography (BLUE) surfaces bilaterally, or when indicated, can be performed protocol and include the upper, lower, and posterior- with a patient-focused abbreviated approach. Typically, lateral alveolar pleural syndrome views. However, it is the transthoracic scanning window will be used for the important to note that the BLUE protocol was developed examination of the lung and pleura [36]. The intercostal for hypoxemic patients to improve the diagnostic tree spaces serve as scanning windows. The transducer quality and avoid false negative results, without undue should be positioned at right angles to the ribs so that modification of the treatment plan [66]. In addition, two adjacent ribs are captured. This allows the lung three conventional anatomic areas (anterior, lateral, and to slide, i.e. the movement of the pleura visceralis, posterior) can be identified at each hemithorax by using reliably identified and from the anterior rib artifact the anterior and posterior axillary lines as landmarks can be distinguished. By using these techniques, [37]. In Austria, Switzerland and Germany we have each intercostal space of upper and lower parts of the adopted a modified BLUE point protocol for COVID-19 patients to include 6 additional views (Figure 14). 14 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper Figure 15: CT-Topogram of a lung detected a pneumothorax on the right side which was afterwards treated with a Bülau-Drainage. Basic lung exam By using lung ultrasound, the following clinical form, and for guiding chest drainage as an emergency indications should be excluded or confirmed. Pleural life-saving procedure. The diagnosis of pneumothorax effusion, pulmonary edema/interstitial syndrome, traditionally has been based on chest radiography. atelectasis, pneumonia and pneumothorax [67]. Although up to 50% of cases can only be detected using The diagnosis of peripheral pulmonary embolisms is HR-CT, that is not the case using plain chest radiography possible, but it is usually very time-consuming, because because of anterior air collection [68]. In this setting, the complete lung must be systematically examined. lung ultrasound provides much better accuracy for Ultrasound guided thoracentesis allows for direct the early detection of pneumothorax. A large visualization of the drain placement and additional meta-analysis study revealed that lung ultrasound follow-up as clinically necessary. provided better sensitivity than plain chest radiography Pneumothorax (91% v 50%) with similar specificity for pneumothorax (98% v 99%) [37, 69–70] (Figures 15–16). Lung ultrasound is a sensitive and specific technique for identifying pneumothorax, including the occult siemens-healthineers.com/ultrasound 15 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease a.) b.) Figure 16: Follow-up examination of the same patient two days later in the ICU. In M-mode (a.), the absence of motion is documented as a static pattern of horizontal lines (“stratosphere sign”). In comparison to the M-mode (b.), the seashore sign is clearly visible. 5 5C1 Abd Tx Power 100% MI 0.91 TIS 0.8 TIB 0.8 Dyn R 63 dB THI 3.6 MHZ 0 dB 35 fps B-lines Pleura 13 cm Figure 17: COVID-19 pneumonia. Follow-up examination in the ICU using a curved transducer. Ultrasound findings including pleural thickening and irregularity. Additionally, consolidations of the lung with B-lines are detected. 16 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 5 5P1 Lung Tx Power 100% MI 0.79 TIS 1.0 Pleura TIB 1.0 Dyn R 76 dB 3.6 MHZ 0 dB 62 fps B-lines 8 cm Figure 18: COVID-19 pneumonia. Follow-up examination in the ICU using a sector transducer. Ultrasound findings including pleural thickening and irregularity. Additionally, consolidations of the lung with B-lines are detected. Pneumonia tion [72–73]. The pneumonic infiltrate presents itself as low-echo structures with irregular borders and Pneumonic infiltrates can be visualized by ultrasound if inhomogeneous echo texture [74]. they are close to the pleura. Central lung pneumonia could not be detected. In critically ill patients, pneumonia Reissig et al. conducted a prospective, multi-center usually spreads to the periphery, so that it can be easily study on the accuracy of lung ultrasound in the diagnosis detected by lung ultrasound [30, 66] (Figures 17–18). and follow-up of community-acquired pneumonia [75]. In 362 patients in 14 centers, lung ultrasound had a B-line artifacts are often seen in the areas adjacent to the sensitivity of 93.4% and a specificity of 97.7% for consolidation, likely as an expression of inflammatory pneumonia compared to the reference of final clinical perilesional edema. Pleural line abnormalities and pleural diagnosis. Breath-dependent motion of infiltrates was effusions were consistently associated with areas of seen in 97.6% of the cases, an air bronchogram in confluent B-line artifacts and/or lung consolidation 86.7%, blurred margins in 76.5% and a basal pleural [39, 71]. effusion in 54.4% [72, 75]. Meta-analyses confirmed Sonographically, in pneumonia, the lungs typically that pneumonia can be diagnosed using lung ultrasound exhibit two key ultrasound signs, B-lines and consolida- [16, 76] (Figure 19). siemens-healthineers.com/ultrasound 17 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 5C1 Abd Tx Power 100% MI 0.94 TIS 0.7 Consolidation with TIB 0.7 ASC 1 air bronchogram DTCE Med Dyn R 63 dB THI 3.6 MHZ -2 dB 27 fps 12 cm Figure 19: COVID-19 pneumonia. Follow-up examination in the ICU using a curved transducer. Ultrasound findings showed large areas of consolidation in the left posterior upper area and an air bronchogram sign. Atelectasis pleural effusion is transthoracic ultrasound [78–79]. With the transducer in sagittal position to the ribs, Lung atelectasis is common after cardiac surgery, with a pleural effusion appears in a quadrangular space defined reported incidence of up to 88% [77]. The lung sliding by the pleural line (chest wall), the shadows of the ribs sign may be absent in these cases because the alveoli are and the lung line (visceral pleura) – also called “quad not ventilated, which is associated with decreased lung sign” [72] (Figures 21–22). volume and an upward displacement of the diaphragm dome [37] (Figure 20). The effusion volume (V) in milliliters could be measured with the simplified formula. The formula contains The echogenicity of a complete atelectasis of the lungs maximum effusion height (ME [cm]) and the measure- looks very similar to liver tissue [72]. Ultrasound could ment of the basal diaphragm-lung distance (DL [cm]) detect small hyperechoic areas in the bronchioles which [80]. present a trapped partially air-filled area [35]. (V [ml] = (ME [cm] + DL [cm]) x 70) Pleural effusion It measures only a rough estimate of the effusion The sonographic examination of pleural effusions has volumes, since the variable geometric shape during already been established as a routine method since the respiration. With larger pleural effusions, it is often sixties [30]. The most sensitive method for detecting possible to develop compression atelectasis. 18 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper DAX H Sequoia *ABD TIB:0.80 Slight dystelectasis TIC:3.29 in the left lower lobe TIS:0.80 MI:1.18 20fps 95% 2D H Mid 0dB/DR70 13cm Figure 20: Pleural effusion and slight dystelectasis of the left lower lobe. 5C1 Abd Tx Power 100% MI 0.93 TIS 0.7 TIB 0.7 ASC 1 DTCE Med Dyn R 63 dB THI 3.6 MHZ 0 dB 31 fps Pleural effusion 14 cm Figure 21: Pleural effusion right side. siemens-healthineers.com/ultrasound 19 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 5C1 H Sequoia *ABD TIB:0.76 TIC:3.05 TIS:0.76 MI:1.12 27fps 98% Nodular structure 2D adherent to the H High diaphragm 0dB/DR70 13cm Figure 22: Pleural effusion left side and adherent nodular structure to the diaphragm is detected. 5C1 Abd Tx Power 100% MI 0.91 TIS 0.8 TIB 0.8 Dyn R 63 dB Multiple diffused B-lines THI 3.6 MHZ and “white lung” sign 0 dB 35 fps 13 cm Figure 23: COVID-19 pneumonia. Follow-up examination in the ICU using a curved transducer (5–1 MHz). Ultrasound findings including pleural thickening and irregularity. Additionally, consolidations of the lung with B-lines are detected. 20 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 5C1 Sequoia Schallkopf 1 ABD Std Nadel Ausgesteckt 11 cm Figure 24: COVID-19 pneumonia. Follow-up examination in the ICU using a curved transducer (5–1 MHz) and the image fusion technique. Ultrasound findings showed large areas of consolidation and an air bronchogram sign. Summary of Coronavirus COVID-19 examination and follow-up In comparison to pneumonia caused by influenza virus, The blood supply and lesion progression in peri- the COVID-19 virus is characterized by rapid transmission pulmonary consolidation can be monitored by using with a high infection and high lethality rate [81–83]. the color or power Doppler technique [86]. In comparison between non-COVID-19 pneumonia and COVID-19 pneumonia, COVID-19 pneumonia is more Currently, ultrasound of the lung is limited in the likely to have a peripheral distribution [84] (Figure 23). diagnosis and treatment of central lung diseases due to the attenuation of sound waves by normal lung and In addition to HR-CT scan and X-ray of the lung, bone tissues. The diagnosis of lung pathologies relies ultrasound can also be used for the diagnosis and on the artifacts of peri-pulmonary lesions [87–88]. follow-up of the disease [85]. The artifacts exist because of an abnormal ratio of air By using a curved transducer (5–1 MHz), the morphology and water contents in alveoli and interstitial tissues. In and changes of subpleural lesions are clearly displayed. order to improve the diagnostic ultrasound lung tool, Due to the option to use even the low-frequency of the the use of an abdominal curved array probe (5–1 MHz) transducer, changes of air and water contents in consoli- seems to be helpful. Typical for the COVID-19 disease dated peri-pulmonary tissues and an air bronchogram are the thickening of the pleural line with pleural sign can be depicted (Figure 24). line irregularity. The pleural line could be unsmooth, discontinuous and interrupted [85, 89] (Figures 25–26). siemens-healthineers.com/ultrasound 21 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 12L3 Lung Tx Power 100% MI 0.94 TIS 0.3 TIB 0.3 SC 2 DTCE Med Dyn R 62 dB THI 6.7 MHZ 0 dB 16 fps Pleura 6.5 cm Figure 25: COVID-19 pneumonia. Follow-up examination in the ICU using a linear (12–3 MHz) transducer. Ultrasound findings including pleural thickening and irregularity are seen. The appearance of B-lines artifacts could vary from focal, to track the evolution of disease during follow-up and to multifocal and confluent pattern. The consolidations to monitor lung recruitment maneuvers. Additional could vary in different patterns, including multifocal ultrasound can track the response to prone position and small subpleural consolidations up to non-translobar and the management of extracorporeal membrane therapy translobar with occasional air bronchograms [5]. Pleural [85]. With increased use of bedside ultrasound in the effusions are uncommon in coronavirus COVID-19 ICU, patients can be protected from unnecessary disease. An indirect sign for recovering is the appearance radiation and therapy delays. The transport of high-risk of A-lines during the recovery phase [85] (Figure 27). patients to X-ray examinations can be avoided. In summary, in our experience, we consider that lung ultrasound will have a major utility for the management of COVID-19 pneumonia in the ICU due to its safety, repeatability, low cost and point of care use. HR-CT may A special thanks to my colleague for her support: be reserved in the follow-up if lung ultrasound is not Ines Schroeder, MD able to answer the clinical question. In our personal Department of Anesthesiology, experience lung ultrasound could be used for rapid University Hospital, LMU Munich, Munich, Germany assessment of the severity of SARS-CoV-2 pneumonia, 22 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 12L3 Lung Effusion Tx Power 100% MI 0.63 TIS 1.2 TIB 1.2 6.2 MHZ -12 dB 18 fp 9.5 cm- Figure 26: COVID-19 pneumonia. Follow-up examination in the ICU using a linear (12–3 MHz) transducer including M-mode and B-mode. Ultrasound findings detected pleural thickening and an additional small pleural effusion. 12L3 Lung Tx Power 100% MI 0.76 TIS 0.4 TIB 0.4 SC 2 DTCE Med Dyn R 62 dB 6.2 MHZ 0 dB 23 fps A-lines 5 cm Figure 27: Follow-up after artificial respiration of COVID-19 pneumonia on a patient in the ICU. An indirect sign for recovering is the appearance of A-lines during the recovery phase. siemens-healthineers.com/ultrasound 23 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease References 1 https://coronavirus.jhu.edu/map.html 14 Gargani L, Picano E. The risk of cumulative radiation exposure Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. in chest imaging and the advantage of bedside ultrasound. Crit 2 Acta Biomed. 2020 Mar 19;91(1):157-160 Ultrasound J. 2015; 7:4. 3 Wujtewicz M, Dylczyk-Sommer A, Aszkiełowicz A, Zdanowski S, 15 Volpicelli G, Elbarbary M, Blaivas M, et al. International Piwowarczyk S, Owczuk R. COVID-19 - what should evidence-based recommendations for point-of-care lung anaethesiologists and intensivists know about it? Anaesthesiol ultrasound. Intensive Care Med 2012; 38:577-91. Intensive Ther. 2020 Mar 20. 16 Volpicelli G. Lung sonography. J Ultrasound Med 2013; 4 Brogi E, Bignami E, Sidoti A, Shawar M, Gargani L, Vetrugno L, 32:165-71. Volpicelli G, Forfori F. Could the use of bedside lung ultrasound 17 Dietrich CF, Gebhard Mathis G, Cui XW, et al. Ultrasound of the reduce the number of chest x-rays in the intensive care unit? pleurae and lungs. Ultrasound Med Biol 2015; 41:351-65. Cardiovasc Ultrasound. 2017 Sep 13;15(1):23 18 Mathis G. Why look for artifacts alone when the original is 5 Blaivas M, DeBehnke D, Phelan MB. Potential errors in the visible? Chest 2010; 137:233; author reply 233-4. diagnosis of pericardial effusion on trauma ultrasound for penetrating injuries. Acad Emerg Med. 2000 Nov;7(11):1261-6 19 Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart 6 Oks M, Cleven KL, Cardenas-Garcia J, Schaub JA, Koenig S, failure: a lung ultrasound study. Cardiovasc Ultrasound 2015; Cohen RI, Mayo PH, Narasimhan M (2014) The effect of point- 13:40. of-care ultrasonography on imaging studies in the medical ICU: a comparative study. Chest146:1574–1577 20 Gargani L. Lung ultrasound: a new tool for the cardiologist. Cardiovasc Ultrasound 2011; 9:6. 7 Dunn MJ, Gwinnutt CL, Gray AJ. Critical care in the emergency department: patient transfer. Emerg Med J. 2007;24(1):40–4. 21 Bouhemad B, Liu ZH, Arbelot C, et al. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator- 8 Tecce PM, Fishman EK, Kuhlman JE. CT evaluation of the associated pneumonia. Crit Care Med 2010; 38:84-92. anterior mediastinum: spectrum of disease. Radiographics. 1994;14(5):973–90. 22 Buddee FW, Johnson DC, Jellins J: Experimental and clinical experiences in the use of ultrasound for the early detection of 9 Brenner DJ, Hall EJ. Computed tomography–an increasing pulmonary emboli: A preliminary report. Med J Aust 1969; 1: source of radiation exposure. N Engl J Med. 2007;357(22): 295–297. 2277–84. 23 Crawford HD, Wild JJ, Wolf PI, Finks JS: Transmission of 10 Tapson VF. Advances in the diagnosis and treatment of acute ultrasound through living human thorax. Ire Trans Med Electron pulmonary embolism. F1000 Med Rep. 2012; 4:9. doi:10.3410/ 1959; 141–146 M4-9. 24 Lichtenstein DA. BLUE-protocol and FALLS-protocol: two 11 Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, applications of lung ultrasound in the critically ill. Chest. 2015 Rouby JJ. Comparative diagnostic performances of auscultation, Jun;147(6):1659-1670. chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1): 25 Weinberger SE, Drazen JM. Diagnostic procedures in respiratory 9–15. diseases. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal 12 Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Medicine. 16th ed. New York, NY: McGraw-Hill; 2005: 1505 - Study Group (CCUSG). Findings of lung ultrasonography of 1508. novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 Mar 12. 26 Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue 13 Mayo PH, Copetti R, Feller-Kopman D, Mathis G, Maury E, Française statement on competence in critical care Mongodi S, Mojoli F, Volpicelli G, Zanobetti M (2019) Thoracic ultrasonography. Chest. 2009; 135 (4): 1050 - 1060. ultrasonography: a narrative review. Intensive Care Med 45:1200–1211.3. 27 Lichtenstein D, Axler O. Intensive use of general ultrasound in the intensive care unit. Prospective study of 150 consecutive patients. Intensive Care Med. 1993; 19 (6): 353 - 355. 24 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 28 Havelock T, Teoh R, Laws D et al. Pleural procedures and 42 Clevert DA, D’Anastasi M, Jung EM. Contrast-enhanced thoracic ultrasound: British Thoracic Society Pleural Disease ultrasound and microcirculation: efficiency through dynamics-- Guideline 2010. Thorax 2010; 65 (02): ii61–76 current developments. Clin Hemorheol Microcirc. 2013;53(1- Piscaglia F, Nolsoe C, Dietrich CF et al. The EFSUMB Guidelines 2):171-86. 29 and Recommendations on the Clinical Practice of Contrast 43 Clevert DA, Jung EM. [Interventional sonography of the liver Enhanced Ultrasound (CEUS): update 2011 on non-hepatic and kidneys]. Der Radiologe. 2013;53(11):962-73. applications. Ultraschall Med 2012; 33: 33–59 44 Chaloupka M, Bischoff R, Pfitzinger P, Lellig E, Ledderose S, 30 Michels G, Breitkreutz R, Pfister R. Value of lung ultrasound in Buchner A, Schlenker B, Stief C, Clevert DA, Apfelbeck M. emergency and intensive care medicine Dtsch Med Wochenschr. Detection of Gleason 6 prostate cancer in patients with 2014 Nov;139(45):2301-7. clinically significant prostate cancer on multiparametric magnetic resonance imaging. Clin Hemorheol Microcirc. 31 Gardelli G, Feletti F, Nanni A et al. Chest ultrasonography in the ICU. Respir Care 2012; 57: 773–781 2019;73(1):105-111. 32 Lichtenstein D, Goldstein I, Mourgeon E et al. Comparative 45 Apfelbeck M, Chaloupka M, Schlenker B, Stief CG, Clevert DA. diagnostic performances of auscultation, chest radiography, Follow-up after focal therapy of the prostate with high intensity and lung ultrasonography in acute respiratory distress focused ultrasound (HIFU) using contrast enhanced ultrasound syndrome. Anesthesiology 2004; 100: 9–15 (CEUS) in combination with MRI image fusion. Clin Hemorheol Microcirc. 2019;73(1):135-143. 33 Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care 2014; 4: 1 46 European Society of Radiology (ESR). Abdominal applications of ultrasound fusion imaging technique: liver, kidney, and 34 Lichtenstein DA Lung Ultrasound (in the Critically Ill) Superior to pancreas. Insights Imaging. 2019 Jan 28;10(1):6. CT: The Example of Lung Sliding. Korean J Crit Care Med. 2017 Feb;32 (1):1-8. 47 Schlenker B, Apfelbeck M, Armbruster M, Chaloupka M, Stief CG, Clevert DA. Comparison of PIRADS 3 lesions with 35 Armbruster W, Eichholz R, Notheisen T. Lung Ultrasound for histopathological findings after MRI-fusion targeted biopsy of Anesthesia, Intensive Care and Emergency Medicine the prostate in a real world-setting. Clin Hemorheol Microcirc. Anasthesiol Intensivmed Notfallmed Schmerzther. 2019 Feb;54 2019;71(2):165-170. (2):108-127 48 Rübenthaler J, Wilson S, Clevert DA. Multislice computed 36 Michels G, Breitkreutz R, Pfister R. Value of lung ultrasound in tomography/contrast-enhanced ultrasound image fusion as a emergency and intensive care medicine Dtsch Med Wochenschr. tool for evaluating unclear renal cysts. Ultrasonography. 2019 2014 Nov;139 (45):2301-7 Apr;38(2):181-187. 37 Efremov SM, Kuzkov VV, Fot EV, Kirov MY, Ponomarev DN, 49 Schlenker B, Apfelbeck M, Buchner A, Stief C, Clevert DA. Lakhin RE, Kokarev EA. J Lung Ultrasonography and Cardiac MRI-TRUS fusion biopsy of the prostate: Quality of image fusion Surgery: A Narrative Review. Cardiothorac Vasc Anesth. 2020 in a clinical setting. Clin Hemorheol Microcirc. 2018;70(4):433- Jan 23. 440. 38 Ziskin, M. C, et al. The comet tail artifact.” J Ultrasound Med. 50 Jung EM, Clevert DA. Contrast-enhanced ultrasound (CEUS) and (1982)., 1, 1-7. image fusion for procedures of liver interventions. Radiologe. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, 2018 Jun;58(6):538-544 39 Atkinson NS, Cui XW, Fan M, Yi D (2016) Lung B-line artefacts 51 Apfelbeck M, Clevert DA, Ricke J, Stief C, Schlenker B. Contrast and their use. J Thorac Dis 8:1356–1365 enhanced ultrasound (CEUS) with MRI image fusion for 40 Lesser TG. Significance of Thoracic and Lung Ultrasound in monitoring focal therapy of prostate cancer with high intensity Thoracic Surgery. Ultraschall Med. 2017 Dec;38(6):592-610. focused ultrasound (HIFU). Clin Hemorheol Microcirc. 2018;69(1-2):93-100. 41 Goffi A, Kruisselbrink R, Volpicelli G. The sound of air: point-of care lung ultrasound in perioperative medicine. Can J Anesth 52 Müller-Peltzer K, Rübenthaler J, Reiser M, Clevert DA. Contrast- 2018; 65: 399–416. enhanced ultrasound (CEUS) of the liver: Critical evaluation of use in clinical routine diagnostics Radiologe. 2017 May;57(5):348-355. siemens-healthineers.com/ultrasound 25 HOOD05162003083241 10 April 2020 White paper · Lung Ultrasound in Patients with Coronavirus COVID-19 Disease 53 Rübenthaler J, Paprottka KJ, Marcon J, Reiser M, Clevert DA. MRI 64 Rennert J, Georgieva M, Schreyer AG, Jung W, Ross C, and contrast enhanced ultrasound (CEUS) image fusion of renal Stroszczynski C, et al. Image fusion of contrast enhanced lesions. Clin Hemorheol Microcirc. 2016;64(3):457-466. ultrasound (CEUS) with computed tomography (CT) or magnetic resonance imaging (MRI) using volume navigation 54 Zimmermann H, Rübenthaler J, Paprottka P, Paprottka KJ, Reiser M, Clevert DA. Feasability of contrast-enhanced ultrasound with for detection, characterization and planning of therapeutic image fusion of CEUS and MS-CT for endovascular grafting in interventions of liver tumors. Clin Hemorheol Microcirc. infrarenal abdominal aortic aneurysm in a single patient. Clin 2011;49(1-4):67-81. Hemorheol Microcirc. 2016;64(4):711-719. 65 Soummer A1, Perbet S, Brisson H, Arbelot C, Constantin JM, Lu Q, Rouby JJ; Lung Ultrasound Study Group. Ultrasound 55 Paprottka PM, Zengel P, Cyran CC, Paprottka KJ, Ingrisch M, Nikolaou K, Reiser MF, Clevert DA. Evaluation of multimodality assessment of lung aeration loss during a successful weaning imaging using image fusion with MRI and CEUS in an trial predicts postextubation distress Crit Care Med. 2012 experimental animal model. Clin Hemorheol Microcirc. Jul;40(7):2064-72. 2015;61(2):143-50. 66 Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. 56 Jung EM, Clevert DA. Possibilities of sonographic image fusion: Current developments Radiologe. 2015 Nov;55(11):937-48. Chest 2008; 134:117–25. Paprottka PM, Zengel P, Cyran CC, Ingrisch M, Nikolaou K, 67 Lichtenstein DA. Ultrasound in the management of thoracic 57 Reiser MF, Clevert DA. Evaluation of multimodality imaging disease. Crit Care Med 2007; 35 (05): S250–261 using image fusion with ultrasound tissue elasticity imaging in 68 Ball CG, Ranson K, Dente CJ, et al. Clinical predictors of occult an experimental animal model. Clin Hemorheol Microcirc. pneumothoraces in severely injured blunt polytrauma patients: 2014;57(2):101-10. A prospective observational study. Injury 2009; 40:44–7. 58 Clevert DA, Jung EM. Interventional sonography of the liver and 69 Staub LJ, Biscaro RRM, Kaszubowski E, et al. Chest kidneys Radiologe. 2013 Nov;53(11):962-73. ultrasonography for the emergency diagnosis of traumatic 59 Clevert DA, D’Anastasi M, Jung EM. Contrast-enhanced pneumothorax and haemothorax: A systematic review and ultrasound and microcirculation: efficiency through dynamics-- meta-analysis. Injury 2018; 49:457–66. current developments. Clin Hemorheol Microcirc. 2013;53 70 Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of (1-2):171-86. ultrasonography for the detection of pneumothorax. Chest 60 Clevert DA, Paprottka PM, Helck A, Reiser M, Trumm CG. Image 2012; 141:703–8. fusion in the management of thermal tumor ablation of the 71 Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound liver. Clin Hemorheol Microcirc. 2012;52(2-4):205-16. characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 2013; 48:280-7. 61 Helck A, Notohamiprodjo M, Danastasi M, Meinel F, Reiser M, Clevert DA. Ultrasound image fusion - clinical implementation 72 Radzina M, Biederer J. Ultrasonography of the Lung.Rofo. and potential benefits for monitoring of renal transplants. Clin 2019 Oct;191(10):909-923 Hemorheol Microcirc. 2012;52(2-4):179-86. 73 Lichtenstein DA, Lascols N, Mezi ere G, et al. Ultrasound 62 Clevert DA, Helck A, Paprottka PM, Zengel P, Trumm C, diagnosis of alveolar consolidation in the critically ill. Intensive Reiser MF. Ultrasound-guided image fusion with computed Care Med 2004;30: 276–81. tomography and magnetic resonance imaging. Clinical utility for imaging and interventional diagnostics of hepatic lesions 74 Reissig A, Gorg C, Mathis G. Transthoracic sonography in the Radiologe. 2012 Jan;52(1):63-9. diagnosis of pulmonary diseases: a systematic approach. Ultraschall Med 2009; 30: 438–454 63 Clevert DA, Helck A, D’Anastasi M, Gürtler V, Sommer WH, Meimarakis G, Weidenhagen R, Reiser M. Improving the follow 75 Reissig A, Copetti R, Mathis G et al. Lung ultrasound in the up after EVAR by using ultrasound image fusion of CEUS and diagnosis and follow-up of community-acquired pneumonia: MS-CT. Clin Hemorheol Microcirc. 2011;49(1-4):91-104 a prospective, multicenter, diagnostic accuracy study. Chest 2012; 142: 965–972 26 siemens-healthineers.com/ultrasound HOOD05162003083241 10 April 2020 Lung Ultrasound in Patients with Coronavirus COVID-19 Disease · White paper 76 Blaivas M. Lung ultrasound in evaluation of pneumonia. 87 Liu J, Feng X, et al. New guidelines for ultrasonic diagnosis of J Ultrasound Med 2012; 31:823-6. neonatal lung diseases. Chinese Journal of Contemporary Pediatrics 2019; 21(02):105-113. 77 Badenes R, Lozano A, Belda FJ. Postoperative pulmonary dysfunction and mechanical ventilation in cardiac surgery. 88 Leech M, Bissett B, Kot M, et al. Lung ultrasound for critical care Crit Care Res Pract 2015; 2015:1–8. physiotherapists: a narrative review. Physiother Res Int 2015; 78 Colins JD, Burwell D, Furmanski S et al. Minimal detectable 20(2): 69-76. pleural effusions. A roentgen pathology model. Radiology 89 Yi Huang, Sihan Wang, Yue Liu, Yaohui Zhang, Chuyun Zheng, 1972; 105: 51–53 Yu Zheng, Chaoyang Zhang, Weili Min, Huihui Zhou, Ming Yu, Gryminski J, Krakowka P, Lypacewicz G. The diagnosis of pleural Mingjun Hu A preliminary study on the ultrasonic 79 effusion by ultrasonic and radiologic techniques. Chest 1976; manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19) https://ssrn.com/ 70: 33–37 80 Hassan M, Rizk R, Essam H, et al. Validation of equations for pleural effusion volume estimation by ultrasonography. J Ultrasound 2017; 20:267–71. 81 World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected, interim guidance [EB/OL]. [2020-01-13]. https://www.who.int/publications-detail/clinical-management- of-severe-acute-respiratory-infection-when -novel-coronavirus- (nCoV)-infection-is-suspected. 82 Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person- to-person transmission: a study of a family cluster. Lancet 2020. DOI: 10.1016/S0140-6736(20)30154-9. 83 Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019.nCoV) in Wuhan, China. J Med Virol 2020. Jan 29. doi:10.1002/jmv.25689. [Epub ahead of print]. 84 Bai HX, Hsieh B, Xiong Z, Halsey K, Choi JW, Tran TML, Pan I, Shi LB, Wang DC, Mei J, Jiang XL, Zeng QH, Egglin TK, Hu PF, Agarwal S, Xie F, Li S, Healey T, Atalay MK, Liao WH. Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT. Radiology. 2020 Mar 10:200823. doi: 10.1148/radiol.2020200823. [Epub ahead of print] 85 Peng QY1, Wang XT2, Zhang LN3; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 Mar 12. doi: 10.1007/s00134-020-05996-6. 86 Yin W, Li Y, Zeng X, et al. The utilization of critical care ultrasound to assess hemodynamics and lung pathology on ICU admission and the potential for predicting outcome. PLoS One 2017; 12(8): e0182881. siemens-healthineers.com/ultrasound 27 HOOD05162003083241 10 April 2020 At Siemens Healthineers, our purpose is to enable Standalone clinical images may have been cropped healthcare providers to increase value by empowering to better visualize pathology. The products/features them on their journey towards expanding precision mentioned in this document may not be commercially medicine, transforming care delivery, and improving available in all countries. Due to regulatory reasons, patient experience, all enabled by digitalizing healthcare. their future availability cannot be guaranteed. 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