Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : OC21 - OC25 Full Version

Focused Ultrasonography in COVID-19: A Prospective Cross-sectional Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53176.16497
Manju Mathew, Antony Kalliath

1. Assistant Professor, Department of Critical Care, Pushpagiri Medical College Hospital, Thiruvalla, Kerala, India. 2. Senior Resident, Department of Critical Care, Pushpagiri Medical College Hospital, Thiruvalla, Kerala, India.

Correspondence Address :
Manju Mathew,
Pushpagiri Medical College Hospital, Thiruvalla, Pathanamthitta, Kerala, India.
E-mail: dr.tresamaria@gmail.com

Abstract

Introduction: The Coronavirus disease-2019 (COVID-19) pandemic requires adaptation of the care delivery process. Since the point of care ultrasonography (USG) is an essential diagnostic tool that aids in making clinical management decisions in a short time, wider adoption of USG by general health practitioners dealing with COVID-19 patients across the country could improve the care delivery process in a pandemic scenario. A simple diagnostic algorithm of USG limited to two echo views was proposed for ease of training and broader adoption of the technique. The study analysed the efficacy of focused USG in COVID-19 using this approach for diagnosing and managing critically ill COVID-19 patients.

Aim: To determine the concordance between ultrasonographic diagnosis based on a focused algorithm and clinical diagnosis in COVID-19 patients.

Materials and Methods: A prospective cross-sectional study was conducted on 58 COVID-19 positive patients admitted to the COVID-19 Intensive Care Unit (ICU) of a tertiary care hospital, in Kerala, India from October 2020 to March 2021. The inclusion criteria were age 18 years or above, hypoxaemia (SpO2<94%) and hypotension (systolic blood pressure <90 mmHg). Apical four chamber and subcostal views were captured using a phased array probe (1.7-4 Hz). The cause of hypoxaemia or hypotension was diagnosed based on an algorithm constructed with Echocardiographic (ECHO) findings in COVID-19. A clinical diagnosis was made, laboratory data, and chest radiograph. Agreement between ultrasonographic and clinical diagnosis was assessed using the Cohen’s Kappa inter-rater coefficient. Statistical Package for the Social Sciences (SPSS) version 20 was used for the statistical analysis.

Results: Mean age of the population was 65.6±17.3 years, and the male to female ratio was 1.5:1. Clinical diagnoses were categorised into six groups. The agreement between the ultrasonographic and the clinical diagnoses was substantial (95.1%), with Kappa 0.905 (0.851-0.959). The median time taken for image acquisition was 30 seconds (IQR 30, 60). Additional views performed for lungs and vessels did not change the clinical diagnosis or management.

Conclusion: The proposed technique is simple yet effective for clinical management decisions. It has the potential for improving patient care delivery on a larger scale, since it reduces the time lag in instituting therapy.

Keywords

Coronavirus disease-2019, Critical illness, Diagnostic imaging, Pandemic, Ultrasound

In mid 2020, the sudden influx of patients due to the COVID-19 pandemic overwhelmed the surge capacity of the limited health resources across the country. The care delivery process had to be adapted to deal with this crisis. A problem oriented bedside USG helps acquire relevant diagnostic information, enabling management decisions (1),(2),(3). Furthermore, it reduces the risk of disease transmission (4). Most of COVID-19 patients who require ICU admission, have hypoxaemia, along with bilateral infiltrates in Chest X-ray (CXR). In addition, most of them have multiple comorbidities. Hypoxaemia may be caused by factors other than COVID-19 pneumonia, such as cardiogenic pulmonary oedema or fluid overload as in kidney failure. It is essential to quickly screen for these factors to administer precise treatment. Point of care USG, including heart and Inferior Vena Cava (IVC), aids in rapid differentiation between pulmonary and other causes of hypoxaemia on admission (5),(6).

As the pandemic surged, doctors from different specialities managed COVID-19 patients in the ICU, along with physicians and intensivists. USG was already part of the bedside decision making process, and it became essential to train all doctors involved in ICU patient management in USG to make timely decisions. A consistent and systematic approach of USG examination had to be developed to ensure that all patients received optimal treatment. The learning process involved: image acquisition and interpretation; a standardised algorithm to rule out causes of hypoxaemia and hypotension other than COVID-19 pneumonia. A brief core USG examination which could be taught in a few short training sessions and reinforced by repetition during daily rounds, was necessary.

The standard intensive care USG includes apical four chamber (4C), parasternal long axis, short axis and subcostal views, and multiple views for lung, abdomen, and vessels. However, a quick screening of the heart and IVC using one or two views is often employed in ICU during an emergency to derive critical information (5),(6),(7). In this study, apical 4C and subcostal views were chosen for the core USG examination. These two views, which essentially look at the size and function of all four chambers of the heart and IVC, were presumed to provide information to distinguish the cause of hypoxaemia and hypotension in COVID-19 patients and guide fluid therapy (5),(6). A similar approach using the subcostal view alone for ten seconds is currently being practised for determining the cause of cardiac arrest in advanced cardiac life support (8). A systematic review on training in point of care USG found that studies conducted with simplified imaging goals to address specific clinical questions with binary outcomes like abnormality present or absent had increased accuracy in the hands of trainees (6). Successful mastering of the technique and reducing errors depended upon the experience of repetition of limited learning parameters (7),(9),(10).

An algorithm was constructed based on ECHO features reported in COVID-19 to rule out the possible aetiologies for hypoxaemia and hypotension in COVID-19. Hypoxaemia and hypotension in COVID-19 may be caused by coronary or pulmonary thrombosis, myocarditis, diarrhoea, shock and renal failure. However, COVID-19 primarily affects the pulmonary system causing pneumonia or Acute Respiratory Distress Syndrome (ARDS) (11). There is abundant literature on USG in COVID-19 (12),(13),(14),(15). ECHO features of COVID-19 in the published studies include Left Ventricle (LV) systolic or diastolic dysfunction, Regional Wall Motion Abnormality (RWMA) suggestive of Acute Coronary Syndrome (ACS), acute myocarditis, Right Ventricle (RV) dilatation and dysfunction (McConnell’s sign) in Pulmonary Thromboembolism (PTE) and stress induced cardiomyopathy characterised as RWMA or apical ballooning of LV (16).

This study looked into the efficacy of an approach limited to two views, apical 4C and subcostal, to determine the cause of hypoxaemia and hypotension in COVID-19, guided by an algorithm. The study’s primary objective was to determine the concordance between the ultrasonographic diagnosis using the proposed technique and diagnosis based on clinical and laboratory data.

Material and Methods

This was a hospital based cross-sectional study, conducted between October 2020 to March 2021, at Pushpagiri Medical College hospital, Kerala, India. It is a tertiary care teaching hospital in Kerala, with a critical care residency program that includes bedside ultrasound training. The study was approved by the Institutional Review Board and Ethics Committee (no. II/27/2020) and was registered at the clinical trials registry India (ICMR no.2020/10/037526).

Inclusion criteria: COVID-19 positive (RT-PCR or antigen assay) patients with moderate and severe respiratory involvement as per the disease classification by the COVID-19 national task force, government of India (17) or other critical illnesses were admitted into a designated COVID-19 ICU where isolation precautions were taken. From these patients admitted in the COVID-19 ICU, those who met the inclusion criteria were included in the study. COVID-19 positive (RT-PCR or antigen assay), age ≥18 years, hypoxaemia (SpO2<94%) or hypotension (systolic blood pressure <90 mmHg) or both.

Exclusion criteria: Patients who did not give consent or in whom image acquisition was impossible and patients with indefinite clinical diagnosis was excluded.

Sample size calculation: Sample size was determined by the formula

The minimum sample size calculated using the above formula was 47 using z=1.96, ? _error 5%, 10.0 precision and 14% prevalence. Here, prevalence refers to the proportion of hospitalised COVID-19 patients admitted to the ICU (18).

Study Procedure

Focused USG, based on a charted algorithm (Table/Fig 1), was performed in this group ensuring adequate isolation precautions, by a certified intensivist with eight years of experience in performing USG on the critically ill. A dedicated portable ultrasound machine (Vivid E by Wipro GE healthcare limited, China, 2016, version 6.0.4) with phased array, curvilinear and linear array probes were used for procuring images. Apical 4C and subcostal views were captured and recorded with the phased array probe (1.7-4 Hz). Both views were used for assessment by visual estimation of: a) RV size and function; and b) LV size and function/RWMA. A long axis view of the IVC for maximum diameter and the presence of respiratory variability was obtained with the subcostal view. These were used for assessment of volume status. Subcostal 4C served as an alternate view when the apical 4C view was poor. The images were then reviewed immediately to reach an USG based diagnosis for the cause of hypoxaemia or hypotension, which was documented (Table/Fig 2). When required these images were saved to allow remote interpretive assistance from cardiologists. Image acquisition was done for 3-4 cardiac cycles, and the time taken was documented. The time required for image acquisition was defined as the time point from when the physician started using the probe for image acquisition of the apical 4C view, subsequently proceeding to the subcostal view and the end time point was when these two images were captured.

Additional views taken were documented, and findings were assessed to see their contribution to the diagnosis or treatment. Clinical diagnosis was decided by two intensivists treating the patient, based on the clinical details, laboratory data, imaging, and consultative calls documented. All patients had CXR and Electrocardiogram (ECG).

The primary outcome was agreement between ultrasonographic diagnosis and clinical diagnosis. Secondary outcomes were to estimate the time required for the acquisition of images as per the study protocol and to evaluate whether additional views of the heart, lung, leg veins, abdomen when acquired, aided in gaining critical information for immediate management. Informed written consent for the use of personal data was taken when the patients were deemed competent. In cases where patients could not give consent while in the ICU, informed consent was taken later from the patient or his immediate next of kin.

Statistical Analysis

Assessment of the level of agreement between ultrasonographic diagnosis and clinical diagnosis was done by employing the cohen’s kappa inter-rater coefficient. Value assumed by the coefficient was reported with the 95% confidence intervals, and p-value <0.01 was considered significant. Statistical Package for the Social Sciences (SPSS) version 20 was used for the statistical analysis.

Results

Out of the 104 patients admitted to the COVID-19 ICU during the study period, 62 met the inclusion criteria. A total of 49 had only hypoxaemia, seven had only haemodynamic instability and six had both. One patient who did not give consent was excluded. Two patients were excluded as image acquisition was impossible. Another patient with an indefinite clinical diagnosis was excluded from the analysis. Data of 58 patients were analysed. Pre-existing heart disease was present in five patients. Common comorbiditieswere diabetes mellitus, hypertension, Chronic Kidney Disease (CKD), chronic Obstructive Airway Disease (OAD), Obstructive Sleep Apnea (OSA),coronary artery disease and Left Ventricular Dysfunction (LVD).Male to female ratio was 1.5:1. The mean age was 65.6±17.3 years. Clinical diagnoses were categorised into six groups. Ultrasonographic findings are shown in (Table/Fig 3).

The agreement between ultrasonographic and clinical diagnosis of cardiogenic pulmonary oedema was 62.5% (k=0.743). The overall agreement between the ultrasonographic and clinical diagnosis was substantial (95.1%), with Kappa coefficient of 0.905 (0.851-0.959) (Table/Fig 4), (Table/Fig 5). The median time taken for image acquisition was 30 seconds (IQR 30, 60). Additional views, performed on 11 patients, did not change the clinical diagnosis or management.

Discussion

This study demonstrated that a problem oriented approach of sonography limited to two ECHO views with the phased array probe by the treating physician could provide sufficient information to make critical management decisions in COVID-19 patients with hypoxaemia or hypotension. The protocol effectively guided fluid therapy based on cardiac and IVC findings. The novelty of study’s novelty is in the emphasis on a core USG examination with limited views for easy mastering of a basic skill set, taking into consideration the lack of trained personnel in the wake of the pandemic. Point of care USG requires a new perspective in the setting of the emergence of COVID-19 for several reasons. Firstly, widespread adoption of USG could be helpful in increasing the efficiency of the healthcare system in the event of a disaster of this kind. Secondly, USG by the clinical personnel who might already be in the isolation room with the patients can restrict additional personnel like sonographers thus ensuring optimal use of PPE kits in the pandemic situation.

From early 2020, the literature showed the utility of USG in managing COVID-19. Lung Ultrasound (LUS) was found useful in the early diagnosis of COVID-19 [12,14,15,19]. It is useful for monitoring lung recruitment in ARDS and troubleshooting complications like pneumothorax. However, COVID-19 affects multiple organs (11). In this context, multiorgan USG might yield better diagnostic performance (13). The standard multiorgan USG involves acquisiting multiple views using the curvilinear, phased array and vascular probes for imaging lungs, heart, vessels and abdomen. A vascular probe is helpful to rule out Deep Vein Thrombosis (DVT). However, pulmonary thrombosis in COVID-19 is more likely due to pulmonary vascular and endothelial inflammation than the classical thromboembolism from leg veins (20). More than half of the patients with pulmonary thrombi were not associated with DVT (21) and a computer tomography with pulmonary angiography scan is required to rule out pulmonary thrombosis. The benefits concurred by an additional vascular probe to rule out DVT in all COVID-19 cases is thereby limited. The Lung Ultrasound (LUS) requires advanced expertise for interpretation. Considering the above mentioned diagnostic complexities, currently, the skills required for performing a multiorgan USG are part of the repertoire of trained intensivists, thus limiting the practical application. The simple two view approach with phased array probe, if widely accepted, can be a framework on which further knowledge in performing a multiorgan protocol can be acquired later [9,10].

Several USG based protocols are available for rapid evaluation of aetiology of shock and hypoxaemia [2,22,23]. A simplified algorithm for diagnosis of both hypoxaemia and hypotension was used in this study, which was based on previously reported ECHO features of COVID-19 (16). The cause of shock in COVID-19 may be sepsis, hypovolemia, cardiac or obstructive (PTE or tension pneumothorax). the IVC maximum diameter and presence of respiratory variability were used as a dynamic method for preload responsiveness and for guiding fluid therapy [24,25]. There are several causes of respiratory failure in these patients other than COVID-19 related pneumonia and ARDS, such as acute pulmonary oedema due to fluid overload or cardiac failure, acute exacerbation of OAD, OSA or complications like pneumothorax or pulmonary embolism.

A study by Volpicelli G et al., found high a level of concordance (k 0.971) between the clinical and ultrasonographic diagnosis in patients admitted to the emergency department with hypotension (2). In comparison, the present study looked into the aetiology of hypoxaemia and hypotension in COVID-19. This study used a combination of USG findings similar to that used by Volpicelli G et al., to diagnose different types of shock and causes of hypoxaemia, except hypovolemic and septic shock.

The ultrasonographic features of hypovolemic and septic shock overlap, making it difficult to differentiate (2). The diagnosis of septic shock was applied to COVID-19 patients with hypotension and normal heart on ECHO. Three patients with hypotension with IVC <0.5 cm with respiratory variability and hyperdynamic LV were grouped under the ultrasonographic diagnosis of hypovolemic shock (22). Another group with difficulty in reaching a diagnosis was patients with pre-existing ECHO abnormalities. They posed a challenge in determining the exact cause of hypoxaemia and shock. In these cases, it was found that the immediate clinical cause of deterioration was not necessarily cardiac. A group of four patients clinically diagnosed with ACS presented with pulmonary oedema or shock. ECHO findings of RWMA and LVD suggested cardiogenic aetiology in this group.

COVID-19 pneumonia was diagnosed based on clinical features and CXR pattern. Troponin I, brain natriuretic peptide and ECG were done in all patients to rule out ACS or LVD as the cause of hypoxaemia or hypotension. The IVC size and respiratory variability guided fluid management in these patients. In patients with CKD, who presented with pulmonary oedema, fluid overload was diagnosed as the cause of hypoxaemia once a cardiac cause was ruled out.

Compression Ultrasound (CUS) performed with a vascular probe to rule out DVT was most common additional view documented in this study. The CUS did not show findings suggestive of DVT in any of the patients in the study group. The LUS was done in a few cases, and a short axis view of the heart was done in one case with suspected RWMA. These additional views would have increased the certainty of diagnosis for the treating doctor but did not change the final management of the patient in this study.

The USG is an affordable, portable, easy to operate, and non ionising imaging modality the can work on battery and is ideally suited for remote and rural places [26,27]. There is enough data on its utility and implementation in various parts of the world like Haiti, Kenya and rural parts of Canada, Australia and New Zealand [26,28]. Surveys from these areas reveal mainly two problems, need for training and quality assurance (29). Technological advancement in the last decade has provided affordable machines with better image quality (30). The USG training has some learning considerations to be addressed. Acquisition of the image is the first step of USG training. It has been shown that repetition of fewer trainable parameters will reduce the chance of technical and interpretive error by novice trainees (6). This idea of using limited views has been exploited by institutions in countries that are already implementing USG training for junior doctors and in rural practice (10). A short memorable USG examination based on two views described in this present study can be the backbone structure for USG training in India. Advanced, specialised imaging can then be expanded upon this knowledge framework.

Despite the indisputable advantages of USG in COVID-19, it is not yet used in the most wanted areas where alternate diagnostic modalities are seldom available (26). The COVID-19 pandemic has created an opportunity for training and adopting newer tools that could continue in the future. Availability of platforms for data transfer, further increases this tool’s desirability for remote settings. The advantage of the proposed technique with limited number of views which can provide maximum information is that it will ease the learning curve leading to wider acceptability and adoption of point of care USG in clinical practice. From an economic standpoint, portable machines with a single probe are more affordable. In addition, this approach which takes less than thirty seconds to two minutes, reduces the time of close contact and risk compared to the standard multiorgan ICU protocol, further encouraging health practitioners to take up this modality in the pandemic setting (4).

Limitation(s)

This was a single centre study limiting the generalisability of the result. Another pitfall of USG is that, respiratory variability of IVC may not be reliable in ARDS patients who are mechanically ventilated with high Positive End Expiratory Pressure (PEEP).

Conclusion

Point of care USG has immense practical utility in critical care delivery in a pandemic scenario. It is well recognised that training in this modality needs to be encouraged. The approach used in this study based on an algorithm using the apical 4C and subcostal views was effective in diagnosing the complications in critically ill COVID-19 patients and managing them. This approach makes training and adoption of this technique simple and less time consuming.

Acknowledgement

Dr. Karthiraj Natarajan for scientific assistance, Manesh Mathew for technical support and Dr. Mathew Pulicken and the Clinical epidemiology unit for departmental and institutional support.

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DOI and Others

DOI: 10.7860/JCDR/2022/53176.16497

Date of Submission: Nov 08, 2021
Date of Peer Review: Dec 27, 2021
Date of Acceptance: Feb 23, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 12, 2022
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• iThenticate Software: Mar 05, 2022 (7%)

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