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Monaldi Archives for Chest Disease 2020; volume 90:1446 Bedside wireless lung ultrasound for the evaluation of COVID-19 lung injury in senior nursing home residents Frank L. Dini1, Carlo Bergamini1, Aldo Allegrini1, Massimo Scopelliti1, Gianmarco Secco2,3, Mario Miccoli4, Stefano Boni5, Raffaella Brigada5, Stefano Perlini2,3 1Medical Workforce, Department of Homeland Security; 2Emergency Department, Fondazione IRCCS Policlinico San Matteo, Pavia; 3Department of Internal Medicine and Therapeutics, University of Pavia; 4Department of Clinical and Experimental Medicine, University of Pisa, Pisa; 5Azienda per la Tutela della Salute, ATS, Pavia, Italy Correspondence: Frank L. Dini, MD, ATS della Provincia di Pavia, Via Abstract Indipendenza, 3, 27100, Pavia, Italy. E-mail: [email protected] Lung Ultrasound (LUS) is regarded to be potentially useful to diagnose lung injury in older adults living in nursing homes with Key words: COVID-19 pneumonia, nasal-pharyngeal swabs, lung ultrasound, elderly. suspected COVID-19 pneumonia. We aimed at evaluating presence lung injury among senior nursing home residents by LUS Contributions:All the authors made a substantive intellectual contribu- performed with portable wireless scanner echography. The study tion, performed part of the experiments. All the authors have read and population consisted ofonly 150 residents with a mean age of 88 years approved the final version of the manuscript and agreed to be account- (85% female) residing in 12 nursing homes in Northern Italy. able for all aspects of the work. Subjects had to have a history of recent onset of symptoms com- Conflict of interest: The authors declare that they have no competing patible with COVID-19 pneumonia or have been exposed to the interests, and all authors confirm accuracy. contagion ofuse patients carrying the disease. COVID-19 testing was performed with SARS-CoV-2 nasal-pharyngeal (NP) swabs. Availability of data and materials: All data generated or analyzed during Positive subjects to LUS scanning were considered those with this study are included in this published article. non-coascelent B-lines in >3 zones, coalescent B-lines in >3 zones Ethics approval and consent to participate: All procedures performed in and with iperdensed patchy non-consolidated lungs. Sixty-three studies involving human participants were in accordance with the ethi- percent had positive NP testing and 65% had LUS signs of pul- cal standards of the Institutional Research Committee and with the 1964 monary injury. LUS had a sensitivity of 79% in predicting positive Helsinki declaration and its latest amendment. Written informed con- NP testing. Sixteen percent of residents tested negative for SARS- sent was obtained from a legally authorized representative(s) for CoV-2 carried the signs of COVID-19 lung injury at LUS. There anonymized patient information to be published in this article. were 92 patients (61%) with current or recent symptoms. Acknowledgments: We sincerely thank Doctor Mara Azzi, General Positivity to LUS scanning was reported in 73% of residents with Manager of the Azienda per la Tutela della Salute (ATS), Pavia, Italy, symptoms, while it was 53% in those without (P=0.016). A posi- Doctor Angelo Borrelli and Doctor Gian Luca Sessa, from the tive NP testing was observed in 66% of residents with symptoms Homeland Security Headquarter, Rome, Italy, for their fundamental and in 57% of those without (P=0.27). We conclude that assess- contribution to direct and organize the Homeland Security COVID-19 ment of LUS by portable wireless scanner echography can be Medical Task Force of the Pavia province. We thank all the staff nurses and physicians of the following nursing homes of the Pavia province: profitability utilized to diagnose lung injury among senior nursing Casa di Riposo Delfinoni, CasorateNon-commercial Primo; Fondazione Galtrucco, home residents with or without symptoms compatible with Robbio; RSA Arcobaleno, Cava Manara; RSA Casa Serena, Cilavegna; COVID-19 pneumonia. RSA La Certosa, Certosa di Pavia; RSA Le Risaie, Marcignago, RSA Pezzani, Voghera; RSA San Gennaro, Varzi; RSA San Giuseppe, Belgioioso; RSA San Giuseppe, Dorno, RSA Sant’Anna, Garlasco; RSA Stradella-Broni, Stradella. Finally, we thank all the staff physicans of the Unità Speciali Continuità Assistenziale (USCA) for their valu- Introduction able contribution to perform COVID-19 nasal-pharyngeal swamps. The SARS-CoV-2 pandemic is impacting the global population Received for publication: 11 June 2020. and community transmission had led to an overwhelming number Accepted for publication: 10 July 2020. of critically-ill patients [1]. Most of patients who are suffering from ©Copyright: the Author(s), 2020 the COVID-19 disease exhibit signs of pulmonary injury that are Licensee PAGEPress, Italy evident from clinical as well as instrumental findings [2]. Monaldi Archives for Chest Disease 2020; 90:1446 Studies have shown that COVID-19 lung disease causes worse doi: 10.4081/monaldi.2020.1446 outcomes and higher mortality in older patients, especially in those with co-morbidities, such as hypertension, heart disease, This article is distributed under the terms of the Creative Commons diabetes, chronic respiratory disease, and chronic kidney disease Attribution Noncommercial License (by-nc 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provid- [3-6]. This may be especially harmful in the elderly population ed the original author(s) and source are credited. living in nursing homes for their baseline co-morbidities and exposures resulting from their congregate settings [7]. [Monaldi Archives for Chest Disease 2020; 90:1446] [page 523] Original Article Lung ultrasound (LUS) is a noninvasive tool for the evaluation 0.2: slight agreement; 0.21-0.40: fair agreement; 0.41-0.60: mod- of lung disease and has the advantage of rapidity, repeatability and erate agreement; 0.61-0.80: substantial agreement; 0.81–1.0: per- reproducibility. Therefore, it is increasingly used by physicians at fect agreement. bedside to complement the findings of physical examination [8,9]. With the introduction of portable echo wireless transthoracic scan- ners, LUS may become a valuable tool to investigate presence of pulmonary injury in the community, especially in patients living Results nursing home facilities, due to their frailty and pandemic vulnera- bility. These considerations have led us to design a study aiming at The study population included 150 residents of 12 nursing evaluating presence lung injury among senior nursing home resi- home facilities of the province of Pavia (Lombardy; Italy) enrolled dents by LUS performed by portable wireless scanner echography. between April 2020 and May 2020. Mean age was 88 years (range: 72-106 years; 85% female). Co-occurring diseases were present in almost all patients. History of hypertension was present in 61%, history of kidney disease in 23%, coronary artery disease in 17%, Methods other heart diseases in 27%, cerebrovascular disease in 29%, atrial fibrillation in 19%, diabetes in 19%, heart failure in 8% and chron- The study population consisted of consecutive subjects resid- ic respiratory disease in 9%. ing in nursing homes. Inclusion criteria were: patients institution- Current or recent symptoms, from moderate to severe, includ- alized in residential age care facilities of Pavia province in Italy ing fever, respiratory symptoms (like cough and dyspnoea), and with a history of recent respiratory symptoms and/or fever or have asthenia were reported in 61%. been in contact with patients that have been previously tested pos- Ninety-eight (65%) of patients had positive LUS findings. itive to SARS-CoV-2 infection. Exclusion criteria included asymp- Among them, score 1 was reported in 36 patients, 32 were classified tomatic residents of nursing homes that were not exposed to the as score 2. Score 3 was observed in 30. LUS showed pleural line infection. abnormalities in 90% of patients,only most of them were irregular and LUS was performed with a portable sector convex/linear wire- discontinued and sometimes fragmented. Sliding was preserved in less CERBERO (ATL, Milano, Italy) probes of 3.5 MHz and 7.5- all but two cases. Signs of pleural effusion were reported in 11 cases. 10 MHz with no harmonic filter, connected with a tablet. Focus Positivity to LUS scanning was reported in 67 patients (73%) with was placed on the pleural line, maximum depth was at 8-10 cm. symptoms, whileuse it was 53% (n=31) in those without (P=0.016). Mechanical index started from 0.7 cm and was reduced as further Nasal-pharyngeal swabs for laboratory testing of SARS-CoV- as possible. All devices were wrapped in single use plastic covers 2 were collected in all study patients within a week from LUS to reduce the risk of contamination and to facilitate the sterilization assessment. Sixty-three percent of them (n=94) resulted positive procedures. Patients were examined in supine or semi-recumbent for SARS-CoV-2 infection. The positive rate of COVID-19 nasal- position. Each hemithorax was divided by the anterior axillary line pharyngeal sampling was 66% (n=61) in patients with symptoms and posterior axillary line into three areas: anterior, lateral and pos- and 57% (n=33) in those without (P=0.27). Table 1 summarizes the terior. Each of these zones was subsequently divided into upper characteristics of the study patients among those presenting symp- and lower zones. The thorax was scanned in eight to twelve inter- toms and/or

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