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where medical students who have trained to recognize cardiovascular disease showed a greater accuracy in their diagnoses using pocket ultrasounds than a trained cardiologist using a traditional physical examination&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> We would like to strongly encourage the medical community to not rely solely on auscultation in patients with dyspnea&#44; reduce their use of X-rays and do selective CT scans in this pandemic&#46; It has been shown that lung ultrasound at the point of care has diminished the use of thorax X-rays by 26&#37;&#44; and a 47&#37; in the use of CT scans that show significant statistical results&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Binomial examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Examining a patient in an intensive care unit &#40;ICU&#41; is done by one person&#44; who both explores and controls image capturing&#46; However&#44; this dynamic is not recommended in the context of SARS-CoV-2&#46; In this case&#44; the exploration carried out in pairs is recommended&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">They will aid and assist the patient and their environment with the necessary personal protective equipment&#46; An explorer &#40;the professional with the most experience and skill&#41; will manipulate the probe&#44; the gel&#44; and the patient&#44; whereas the second one will only control the commands and the screen&#44; recording images and videos alongside the explorer&#44; who will observe and direct&#46; This second participant should not interact with the patient or the objects around them&#44; minimizing the chance for nosocomial and fomite transmission&#46; The pocket equipment should be placed in protective covers &#40;phones&#44; tablets&#44; probes&#41;&#46; Cleaning should be done in proximal-to-distal sweeps without zigzagging&#46; The same procedure should be performed after each new patient&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Gel must be used carefully in order to prevent its contamination and further dissemination of the virus&#46; Allocating a specific amount of gel for each patient is also recommended&#44; since it prevents the patient&#39;s skin&#44; the bottle&#44; and the probe from touching each other&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Examination techniques</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">If the patient is sitting</span><p id="par0020" class="elsevierStylePara elsevierViewall">The thorax will be explored from three different angles by hemithorax &#40;the anterior&#44; lateral&#44; and posterior faces&#41; and in six different segments &#40;Anterior&#58; superior&#47;inferior&#59; Lateral&#58; superior&#47;inferior&#46; Posterior&#58; superior&#47;middle&#47;inferior&#41;&#46; These are fourteen segments in total&#46; The sweep will be performed from median to lateral and downward&#44; placing the probe both transversely and longitudinally&#44; with one mark pointing to the head and in medial position&#46; The findings should be registered according to the segment and the intercostal space in which they were found&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">If the patient is in supine or prone decubitus</span><p id="par0025" class="elsevierStylePara elsevierViewall">The thorax is limited to two faces depending on the patient&#39;s position &#40;anterior&#47;posterior&#41; the lateral sides can be explored as well &#40;superior and inferior&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">BLUE protocol</span><p id="par0030" class="elsevierStylePara elsevierViewall">The BLUE protocol<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> is a standardized diagram for the rapid identification of the causes of dyspnea&#46; 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bilateral B-lines &#40;at least in four points of the anterior chest wall&#41; may indicate cardiogenic or noncardiogenic pulmonary edema&#46; Performing echocardiography may be helpful in this case&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Focal B-lines may indicate interstitial syndrome&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">POCUS findings in COVID-19</span><p id="par0055" class="elsevierStylePara elsevierViewall">The main ultrasound findings reported are summarized in &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Danilo Buonsenso reported<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> an irregular pleural line with small sub pleural consolidations both in the anterior and posterior thorax&#44; a great presence of vertical artifacts&#44; several areas of preserved tissue mixed with sick tissue&#44; and some typical images of interstitial alveolar damage &#40;the same present in some Chinese patients&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> who also reported to have diminished local blood flow&#44; as observed by Doppler&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Add a transverse probe rotation improves the visualization of consolidations increasing in the number of signs visualized &#40;greater length of pleura visualized and constant&#41;&#46; One limitation is the detection of deep lesions due to the blockage of the sonic transmission in an aerated lung&#44; however&#44; makes an excellent tool to observe sub pleural lesions&#44; and vertical artifacts&#44; since most reported cases show that the posterior-inferior fields of the lung are focal points for the disease&#46; If the pneumonia extends beyond the pleural line and the ultrasound does not provide enough clarity in order to understand the clinical course of the disease&#44; a thorax CT scan will be needed&#46; The ultrasound patterns found in the course of COVID-19 were significantly different to those of other lesions reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">POCUS triage for COVID-19</span><p id="par0060" class="elsevierStylePara elsevierViewall">This system will be useful in emerging economies or systems lacking resources&#44; avoiding the saturation of medical services&#59; it is based on an intuitive triage by virtue of the several ultrasound patterns related to COVID-19 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; POCUS triage can help professionals pick out low-risk &#40;green&#41; cases at first contact&#44; which can lead to considering them &#8220;negative by lung ultrasound&#8221; get the test and the subject can be put in isolation&#59; those &#8220;suggestive or positive by lung ultrasound&#8221; &#40;yellow and red&#41; with abnormal patterns ought to be early admitted into ER or ICU&#46; This system allows professionals to determine the severity even at an out-of-hospital phase due to the acknowledgment of any suggestive imaging highly suspicious of severity&#46; With portable or pocket devices at the patient&#39;s bedside the exploration allows re-asses in real time the condition of the critically ill in the ICU reducing time&#44; money and the risk to a nosocomial exposure to the virus through the portable X-ray machines or in non-selective transport to CT scan room&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The present manuscript received no funding&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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Point of view
Routine use of Point-of-Care lung ultrasound during the COVID-19 pandemic
Uso rutinario del ultrasonido pulmonar en el punto de atención durante la pandemia por COVID-19
O.Y. Antúnez-Montesa,b,
Autor para correspondencia
antunezyassef@gmail.com

Corresponding author.
, D. Buonsensoc,d
a Departamento de Docencia e Investigación. Instituto Latinoamericano de Ecografía en Medicina (ILEM), Ciudad de México, Mexico
b SOLJAC MD Servicios Médicos de Emergencia, Aeropuerto Internacional de la Ciudad de México AICM, Mexico
c Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
d Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Superiority of ultrasound versus physical examination and X-ray</span><p id="par0005" class="elsevierStylePara elsevierViewall">Currently&#44; many studies have shown the superiority of lung ultrasound as an auxiliary tool to diagnoses in several respiratory diseases&#44; such as those triggered by SARS-CoV-2&#46; This ought to be stated&#58; lung ultrasound leads to higher diagnostic accuracy than to what auscultations and X-rays allow&#46; A representative article<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> showed how the specificity&#44; the sensibility and the diagnostic accuracy achieved during a lung ultrasound surpassed 93&#37; in all parameters whereas auscultations and X-rays yield variable and little-supported data&#46; Ultrasound is considered to be the fifth pillar of physical examinations&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and there is an open debate on whether ultrasound should replace stethoscopes in certain scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This same scenario has been shown to happen in echocardiography&#44; where medical students who have trained to recognize cardiovascular disease showed a greater accuracy in their diagnoses using pocket ultrasounds than a trained cardiologist using a traditional physical examination&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> We would like to strongly encourage the medical community to not rely solely on auscultation in patients with dyspnea&#44; reduce their use of X-rays and do selective CT scans in this pandemic&#46; It has been shown that lung ultrasound at the point of care has diminished the use of thorax X-rays by 26&#37;&#44; and a 47&#37; in the use of CT scans that show significant statistical results&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Binomial examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Examining a patient in an intensive care unit &#40;ICU&#41; is done by one person&#44; who both explores and controls image capturing&#46; However&#44; this dynamic is not recommended in the context of SARS-CoV-2&#46; In this case&#44; the exploration carried out in pairs is recommended&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">They will aid and assist the patient and their environment with the necessary personal protective equipment&#46; An explorer &#40;the professional with the most experience and skill&#41; will manipulate the probe&#44; the gel&#44; and the patient&#44; whereas the second one will only control the commands and the screen&#44; recording images and videos alongside the explorer&#44; who will observe and direct&#46; This second participant should not interact with the patient or the objects around them&#44; minimizing the chance for nosocomial and fomite transmission&#46; The pocket equipment should be placed in protective covers &#40;phones&#44; tablets&#44; probes&#41;&#46; Cleaning should be done in proximal-to-distal sweeps without zigzagging&#46; The same procedure should be performed after each new patient&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Gel must be used carefully in order to prevent its contamination and further dissemination of the virus&#46; Allocating a specific amount of gel for each patient is also recommended&#44; since it prevents the patient&#39;s skin&#44; the bottle&#44; and the probe from touching each other&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Examination techniques</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">If the patient is sitting</span><p id="par0020" class="elsevierStylePara elsevierViewall">The thorax will be explored from three different angles by hemithorax &#40;the anterior&#44; lateral&#44; and posterior faces&#41; and in six different segments &#40;Anterior&#58; superior&#47;inferior&#59; Lateral&#58; superior&#47;inferior&#46; Posterior&#58; superior&#47;middle&#47;inferior&#41;&#46; These are fourteen segments in total&#46; The sweep will be performed from median to lateral and downward&#44; placing the probe both transversely and longitudinally&#44; with one mark pointing to the head and in medial position&#46; The findings should be registered according to the segment and the intercostal space in which they were found&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">If the patient is in supine or prone decubitus</span><p id="par0025" class="elsevierStylePara elsevierViewall">The thorax is limited to two faces depending on the patient&#39;s position &#40;anterior&#47;posterior&#41; the lateral sides can be explored as well &#40;superior and inferior&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">BLUE protocol</span><p id="par0030" class="elsevierStylePara elsevierViewall">The BLUE protocol<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> is a standardized diagram for the rapid identification of the causes of dyspnea&#46; 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bilateral B-lines &#40;at least in four points of the anterior chest wall&#41; may indicate cardiogenic or noncardiogenic pulmonary edema&#46; Performing echocardiography may be helpful in this case&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Focal B-lines may indicate interstitial syndrome&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">POCUS findings in COVID-19</span><p id="par0055" class="elsevierStylePara elsevierViewall">The main ultrasound findings reported are summarized in &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Danilo Buonsenso reported<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> an irregular pleural line with small sub pleural consolidations both in the anterior and posterior thorax&#44; a great presence of vertical artifacts&#44; several areas of preserved tissue mixed with sick tissue&#44; and some typical images of interstitial alveolar damage &#40;the same present in some Chinese patients&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> who also reported to have diminished local blood flow&#44; as observed by Doppler&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Add a transverse probe rotation improves the visualization of consolidations increasing in the number of signs visualized &#40;greater length of pleura visualized and constant&#41;&#46; One limitation is the detection of deep lesions due to the blockage of the sonic transmission in an aerated lung&#44; however&#44; makes an excellent tool to observe sub pleural lesions&#44; and vertical artifacts&#44; since most reported cases show that the posterior-inferior fields of the lung are focal points for the disease&#46; If the pneumonia extends beyond the pleural line and the ultrasound does not provide enough clarity in order to understand the clinical course of the disease&#44; a thorax CT scan will be needed&#46; The ultrasound patterns found in the course of COVID-19 were significantly different to those of other lesions reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">POCUS triage for COVID-19</span><p id="par0060" class="elsevierStylePara elsevierViewall">This system will be useful in emerging economies or systems lacking resources&#44; avoiding the saturation of medical services&#59; it is based on an intuitive triage by virtue of the several ultrasound patterns related to COVID-19 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; POCUS triage can help professionals pick out low-risk &#40;green&#41; cases at first contact&#44; which can lead to considering them &#8220;negative by lung ultrasound&#8221; get the test and the subject can be put in isolation&#59; those &#8220;suggestive or positive by lung ultrasound&#8221; &#40;yellow and red&#41; with abnormal patterns ought to be early admitted into ER or ICU&#46; This system allows professionals to determine the severity even at an out-of-hospital phase due to the acknowledgment of any suggestive imaging highly suspicious of severity&#46; With portable or pocket devices at the patient&#39;s bedside the exploration allows re-asses in real time the condition of the critically ill in the ICU reducing time&#44; money and the risk to a nosocomial exposure to the virus through the portable X-ray machines or in non-selective transport to CT scan room&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The present manuscript received no funding&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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                  \t\t\t\t">Irregularity or complete interruption of the pleural line&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focal&#44; multifocal and confluent patterns of B lines &#40;vertical artifacts&#41;&#44; patchy areas of white lung&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decrease of lines B &#40;vertical artifacts&#41; and reappearance of lines A in the recovery phase&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decreased or absent Doppler signal in Lung Consolidations &#40;preliminary findings&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pleural effusions are rare&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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