Current best evidence for clinical care (more info)
Background: In this coronavirus disease 2019 (COVID-19) pandemic, fast and accurate testing is needed to profile patients at the emergency department (ED) and efficiently allocate resources. Chest imaging has been considered in COVID-19 workup, but evidence on lung ultrasound (LUS) is sparse. We therefore aimed to assess and compare the diagnostic accuracy of LUS and computed tomography (CT) in suspected COVID-19 patients.
Methods: This multicentre, prospective, observational study included adult patients with suspected COVID-19 referred to internal medicine at the ED. We calculated diagnostic accuracy measures for LUS and CT using both PCR and multidisciplinary team (MDT) diagnosis as reference. We also assessed agreement between LUS and CT, and between sonographers.
Results: One hundred and eighty-seven patients were recruited between March 19 and May 4, 2020. Area under the receiver operating characteristic (AUROC) was 0.81 (95% CI 0.75-0.88) for LUS and 0.89 (95% CI 0.84-0.94) for CT. Sensitivity and specificity for LUS were 91.9% (95% CI 84.0-96.7) and 71.0% (95% CI 61.1-79.6), respectively, versus 88.4% (95% CI 79.7-94.3) and 82.0% (95% CI 73.1-89.0) for CT. Negative likelihood ratio was 0.1 (95% CI 0.06-0.24) for LUS and 0.14 (95% CI 0.08-0.3) for CT. No patient with a false negative LUS required supplemental oxygen or admission. LUS specificity increased to 80% (95% CI 69.9-87.9) compared to MDT diagnosis, with an AUROC of 0.85 (95% CI 0.79-0.91). Agreement between LUS and CT was 0.65. Interobserver agreement for LUS was good: 0.89 (95% CI 0.83-0.93).
Conclusion: LUS and CT have comparable diagnostic accuracy for COVID-19 pneumonia. LUS can safely exclude clinically relevant COVID-19 pneumonia and may aid COVID-19 diagnosis in high prevalence situations.
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Early reviews of ED COVID-19 diagnostics (history, physical exam, imaging) neglected the role of POCUS (http://pmid.us/32542934), instead emphasizing CT as an adjunct to molecular testing. This study provides a foundation for POCUS in experienced hands as a reasonable alternative to CT. Whether the equivalent accuracy of POCUS to CT actually benefits patients in some measurable way remains an unknown (http://pmid.us/9867891).
This is a small nonrandomized trial that should change nothing.
The findings are not surprising and the clinical utility here is not immediately obvious (not sure how this will change clinical management), but it is a methodologically rigorous study that provides useful information about the role of point-of-care US to manage patients with suspected COVID-19.
As an Internist working in a COVID-19 clinic, I found this article very useful.
A strength is using a reference standard including expert opinion.