Use of point-of-care lung ultrasonography in the critical care setting as an aid to identifying the correct diagnosis in an acutely desaturating patient with COVID-19-related acute respiratory distress syndrome

Abstract

A 64-year-old man was intubated and ventilated for COVID-19-associated acute respiratory distress syndrome. He had a background history of chronic obstructive pulmonary disease and ischaemic heart disease. His oxygen saturations dropped rapidly to 80% on day 9 of ICU admission. Chest auscultation revealed absent breath sounds over the left upper chest which raised suspicions for pneumothorax, of which a small stable left apical pneumothorax was documented on a recent CT scan of the thorax. Point-of-care ultrasonography was performed prior to attempting chest drain insertion which demonstrated sliding pleura on the left side (GE Healthcare model: Vscan Extend—display: 5 inches, 720×1280 pixels resolution, sector probe—broad bandwidth: 1.7–3.8 MHz, 24 cm penetration and linear probe—broad bandwidth: 3.3–8 MHz, 8 cm penetration). A portable chest X-ray was obtained which demonstrated left upper lobe collapse secondary to mucus plugging. The mucus plug was successfully suctioned from the patient’s airway using bedside bronchoscopy subsequently improving the patient’s oxygen saturation. A follow-up chest X-ray and CT scan of the thorax demonstrated interval resolution of the left upper lobe collapse. While expansion of his existing pneumothorax was first on the list of differential diagnoses, the use of ultrasonography early in the patient’s assessment ensured it was ruled out prior to attempting chest drain insertion, thus prompting the acquisition of the chest X-ray which subsequently demonstrated the left upper lobe collapse as the correct diagnosis.

Therapeutic and Interventional Bronchoscopy Performed in Critically ill COVID-19 patients: A Systematic Review

“…Additionally, it was well documented in each of the studies that proper use of personnel protection equipment (PPE), googles, double gloves, cap, shoe cover, visor, gown, and filtering face piece level 3 (FFP3) mask [54, 56]. Use of positive pressure hood, bronchoscopy under negative pressure ventilation, regular body temperature checks for HCWs, and weekly RT-PCR.…”

“…The presence of haematic secretions in the distal bronchial tract was found to the reason of high mortality in patients (50). In one COVID-19 patient chest drain was performed due to pneumothorax but oxygenation status did not change post bronchoscopic suction of mucus plug (54). Pulmonary toilet was done by the use of bronchoscopes to remove mucus and secretions in COVID-19 patients [55,[29][30].…”

Current Advances in Lung Ultrasound in COVID-19 Critically Ill Patients: A Narrative Review

“…Second, LUS could be accurate for identifying atelectasy. For example, Lock et al described a sudden drop in oxygenation in an intubated COVID-19 patient with absent breath sounds over the left upper chest but with persistent left pleural sliding in LUS examination, excluding pneumothorax and finally caused by partial ateclectasy of the lung [ 42 ].…”

Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome

“…Loss of pleural sliding can indicate a pneumothorax, though it should be kept in mind that this can also be caused by hyperinflation or collapse. The latter is described by Lock and Nix [ 39 ] in which a sudden drop in oxygenation in combination of loss of pleural sliding was caused by partial collapse of the lung. Furthermore, there are some cases in which the indication of recruitment was made by finding dorso-basal atelectasis [ 40 , 41 ].…”