COVID-19 outbreak: less stethoscope, more ultrasound
Buonsenso D1, Pata D2, Chiaretti A3.
1 Institute of Pediatrics, Department of Woman and Child Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.
2 Institute of Paediatrics, Department of Woman and Child Health, Catholic University of the Sacred Heart, Rome, Italy; Department of Public Health, Catholic University of the Sacred Heart, Rome, Italy. Electronic address: email@example.com.
3 Institute of Pediatrics, Department of Woman and Child Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Institute of Paediatrics, Department of Woman and Child Health, Catholic University of the Sacred Heart, Rome, Italy; Department of Public Health, Catholic University of the Sacred Heart, Rome, Italy.
In their Correspondence in The Lancet Respiratory Medicine, Jonathan Cheung and colleagues stressed the need to ensure staff safety in the airway management of patients with 2019 novel coronavirus disease (COVID-19).1 This safety should be guaranteed from the patient’s first assessment. In fact, maintaining the safety of the doctor, who meets many people during his daily activity, avoids the spread of the disease to other patients and the possible creation of new epidemic outbreaks. However, patients with fever and respiratory symptoms do still need to be seen. The standard method involves doing an objective examination and carrying out any radiological tests, such as chest radiography or chest CT. This means the use of tools such as a stethoscope and radiological devices, with the possibility of contamination of the medical devices and nosocomial spreading of the virus; eventually, this can cause the contagion of health-care workers (from doctor to nurse to radiology technicians) and already hospitalised patients who have a higher risk of developing severe COVID-19.
During such a diffusive outbreak there is still the need to guarantee both the patients’ rights to be evaluated according to the highest standards of care and, at the same time, the health-care workers’ safety. Therefore, it is important that the minimum number of health-care workers and medical devices be exposed to suspected or confirmed cases of COVID-19. In this regard, in 2016, Copetti highlighted how lung ultrasound could have several advantages compared with the use of the stethoscope, to the extent that it could be replaced.2 His famous article entitled “Is lung ultrasound the stethoscope of the new millennium? Definitely yes” was visionary in 2016 and now, in this historical period, very pertinent.
In our opinion, the use of ultrasound is now essential in the safe management of the COVID-19 outbreaks, since it can allow the concomitant execution of clinical examination and lung imaging at the bedside by the same doctor. In order to minimise the use of medical devices and health-care professionals, we introduced a specific procedure for the evaluation of children with suspected COVID-19, based on the use of lung ultrasound by one paediatrician and another assistant, wearing the standard personal protections as per WHO indications.3 The paediatrician prepares the ultrasound pocket device, which comprises a wireless probe and a tablet. The probe and tablet are placed in two separate single-use plastic covers (figure). No other medical devices are used. When the two operators enter the isolation room, the paediatrician uses the probe and does the lung ultrasound, the assistant holds the tablet and freezes and stores the images, touching neither the patient nor the surrounding materials. The stethoscope is not used because it is more difficult to have specific covers and there is a higher probability to mistakenly touch either the ocular or oral mucosa with it. Lung auscultation is therefore substituted by lung visualisation with the ultrasound. After the procedure, in a dedicated area, the operators easily remove the probe and tablet from the covers, simply letting them slip onto clean towels, where the devices are further sterilised.
During a COVID-19 outbreak, it is important to minimise the health care–patient interactions to only the necessary procedures. There are several studies showing the accuracy of lung ultrasound in detecting lung pathologies, from bacterial and viral pneumonia to acute respiratory distress syndrome4 and its non-inferiority to chest x-ray and clinical examination.2, 4 Therefore, we believe that such a procedure could reduce health-care workers’ risk of exposure and also patient movement from the consultation room to the radiology room. Considering the contagiousness of the virus and the need to reduce nosocomial outbreaks, we strongly suggest promotion of lung ultrasound in this setting.