A Lower Global Lung Ultrasound Score Is Associated with Higher Likelihood of Successful Extubation in Invasively Ventilated COVID-19 Patients

Charalampos Pierrakos, Arthur Lieveld, Luigi Pisani, Marry R Smit, Micah Heldeweg, Laura A Hagens, Jasper Smit, Mark Haaksma, Lars Veldhuis, Robin Walburgh Schmidt, Giacomo Errico, Valentina Marinelli, Rachid Attou, Cristina E David, Claudio Zimatore, Francesco Murgolo, Salvatore Grasso, Lucia Mirabella, Gilda Cinnella, David De Bels, Marcus J Schultz, Pieter-Roel Tuinman, Lieuwe D Bos, Charalampos Pierrakos, Arthur Lieveld, Luigi Pisani, Marry R Smit, Micah Heldeweg, Laura A Hagens, Jasper Smit, Mark Haaksma, Lars Veldhuis, Robin Walburgh Schmidt, Giacomo Errico, Valentina Marinelli, Rachid Attou, Cristina E David, Claudio Zimatore, Francesco Murgolo, Salvatore Grasso, Lucia Mirabella, Gilda Cinnella, David De Bels, Marcus J Schultz, Pieter-Roel Tuinman, Lieuwe D Bos

Abstract

Lung ultrasound (LUS) can be used to assess loss of aeration, which is associated with outcome in patients with coronavirus disease 2019 (COVID-19) presenting to the emergency department. We hypothesized that LUS scores are associated with outcome in critically ill COVID-19 patients receiving invasive ventilation. This retrospective international multicenter study evaluated patients with COVID-19-related acute respiratory distress syndrome (ARDS) with at least one LUS study within 5 days after invasive mechanical ventilation initiation. The global LUS score was calculated by summing the 12 regional scores (range 0-36). Pleural line abnormalities and subpleural consolidations were also scored. The outcomes were successful liberation from the ventilator and intensive care mortality within 28 days, analyzed with multistate, competing risk proportional hazard models. One hundred thirty-seven patients with COVID-19-related ARDS were included in our study. The global LUS score was associated with successful liberation from mechanical ventilation (hazard ratio [HR]: 0.91 95% confidence interval [CI] 0.87-0.96; P = 0.0007) independently of the ARDS severity, but not with 28 days mortality (HR: 1.03; 95% CI 0.97-1.08; P = 0.36). Subpleural consolidation and pleural line abnormalities did not add to the prognostic value of the global LUS score. Examinations within 24 hours of intubation showed no prognostic value. To conclude, a lower global LUS score 24 hours after invasive ventilation initiation is associated with increased probability of liberation from the mechanical ventilator COVID-19 ARDS patients, independently of the ARDS severity.

Trial registration: ClinicalTrials.gov NCT04487769.

Figures

Figure 1.
Figure 1.
Pleural line abnormalities (A) and subpleural consolidation (B) identified with lung ultrasound in patient with COVID-19 infection.
Figure 2.
Figure 2.
Three categories of global lung ultrasound (LUS) score and cumulative incidence of outcomes. x-axis: days since intubations; y-axis: probability of an event (extubation or death) in the population. The three facets show the risk for patients with a high risk global LUS score (left), intermediate risk (middle) and low risk global LUS score (right). Red area show the patients who died. Green area shows the patients who were successfully extubated. This figure appears in color at www.ajtmh.org.
Figure 3.
Figure 3.
Forest plot of global lung ultrasound (LUS) score association with probability of successful liberation of invasive ventilation and death at 28 days according to acute respiratory distress syndrome (ARDS) severity and the day of examination after start invasive ventilation. x-axis: hazard ratio for increase of global LUS score for mortality (left) and extubation (right) based on competing risk analysis. The dots provide the point estimate and the lines the 95% confidence interval for estimated associations, stratified for predefined subgroups.

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