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Pulmonary Ultrasound in the Diagnosis and Monitoring of Coronavirus Disease (COVID-19): A Systematic Review

      Abstract

      The goal of this review was to systematize the evidence on pulmonary ultrasound (PU) use in diagnosis, monitorization or hospital discharge criteria for patients with coronavirus disease 2019 (COVID-19). Evidence on the use of PU for diagnosis and monitorization of or as hospital discharge criteria for COVID-19 patients confirmed to have COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) between December 1, 2019 and July 5, 2020 was compared with evidence obtained with thoracic radiography (TR), chest computed tomography (CT) and RT-PCR. The type of study, motives for use of PU, population, type of transducer and protocol, results of PU and quantitative or qualitative correlation with TR and/or chest CT and/or RT-PCR were evaluated. A total of 28 articles comprising 418 patients were involved. The average age was 50 y (standard deviation: 25.1 y), and there were 395 adults and 23 children. One hundred forty-three were women, 13 of whom were pregnant. The most frequent result was diffuse, coalescent and confluent B-lines. The plural line was irregular, interrupted or thickened. The presence of subpleural consolidation was noduliform, lobar or multilobar. There was good qualitative correlation between TR and chest CT and a quantitative correlation with chest CT of r = 0.65 (p < 0.001). Forty-four patients were evaluated only with PU. PU is a useful tool for diagnosis and monitorization and as criteria for hospital discharge for patients with COVID-19.

      Key Words

      Introduction

      Since the first cases were described in the province of Hubei in China, coronavirus has become one of the most important infectious diseases of the century, and by the 20th of September 2020, almost 1 million deaths had been reported worldwide (
      • Arteaga-Livias FK
      • Rodriguez-Morales AJ.
      La comunicación científica y el acceso abierto en la contención de enfermedades: El caso del Coronavirus novel 2019 (2019-nCoV).
      ). Because it is a new disease, many questions concerning its clinical characteristics, diagnosis and treatment remain (
      • Dhama K
      • Khan S
      • Tiwari R
      • Sircar S
      • Bhat S
      • Malik YS
      • Singh KP
      • Chaicumpa W
      • Bonilla-Aldana DK
      • Rodriguez-Morales AJ.
      Coronavirus disease 2019—COVID-19.
      ;
      • Pecho-Silva S
      • Arteaga-Livias K
      • Bazán-Concha BE
      • Navarro-Solsol AC.
      Complicaciones extrapulmonares de la enfermedad por COVID-19.
      ).
      The tools available for diagnosis and monitoring are important to ensure correct clinical decisions and a better comprehension of the evolution of the disease, as well as the possibility of complications in a patient with mild to moderate disease (
      • Henriquez-Marquez KI
      • Zambrano LI
      • Arteaga-Livias K
      • Rodríguez-Morales AJ.
      Prevención e identificación temprana de casos sospechosos COVID-19 en el primer nivel de atención en Centro América.
      ). Diverse authors coincide in that pulmonary ultrasound (PU) can be used in diverse stages of the disease caused by coronavirus disease 2019 (COVID-19), including triage of asymptomatic patients; diagnosis, monitoring and follow-up; evaluation of response to treatment; decision to remove the patient from the mechanical ventilator; and as a criterion for patient discharge (
      • Kristensen MS
      • Teoh WH
      • Graumann O
      • Laursen CB.
      Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae.
      ;
      • Gargani L
      • Soliman-Aboumarie H
      • Volpicelli G
      • Corradi F
      • Pastore MC
      • Cameli M.
      Why, when, and how to use lung ultrasound during the COVID-19 pandemic: Enthusiasm and caution.
      ;
      • Soldati G
      • Smargiassi A
      • Inchingolo R
      • Buonsenso D
      • Perrone T
      • Briganti DF
      • Perlini S
      • Torri E
      • Mariani A
      • Mossolani EE
      • Tursi F
      • Mento F
      • Demi L
      Is there a role for lung ultrasound during the COVID-19 pandemic?.
      ). PU would also have an additional advantage over chest x-ray (CXR) and chest computed tomography (CT), as it is a procedure that can be performed with portable equipment, thereby minimizing patient mobilization and the number of healthcare personnel required and, thus, reducing the number of professionals exposed to a possible contagion (
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Pecho-Silva S.
      Rol del ultrasonido pulmonar en el diagnóstico de la neumonía por SARS-CoV-2: ¿Alternativa a la escasez de tomógrafos?.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ).
      Some articles have been published on the use of PU in COVID-19, as have reviews with fewer than 60 patients (
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ). The number of articles published has increased rapidly; therefore, it is imperative to have up-to-date data on this topic to facilitate decision-making.
      This review aims to systemize the published evidence on the use of PU in the diagnosis and follow-up and as a criterion for discharge of patients with COVID-19, and to evaluate its correlation with other diagnostic procedures such as CXR, chest CT and tests of reverse transcription polymerase chain reaction (RT-PCR).

      Methods

      Search strategies

      This study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist. The protocol is available in the Figshare repository (

      Taype-Rondan A. Protocol systematic review PU. figshare 2020. Available at: https://figshare.com/articles/preprint/Protocol_systematic_review_PU/12680849/1.

      ). A systematic search was carried out in the following databases (between December 1, 2019 and July 5, 2020), with the following terms:
      Pubmed: ("2019/12/01"[Date–Publication]: "2020/07/05"[Date–Publication]) AND ([((lung or chest or pulmo* or thora*) and (ultraso* or sonog* or echography)) and (Covid* or SARS* or coronavirus*)]).
      Scopus: [(TITLE–ABS–KEY (*coronavirus OR sars* OR covid* ) AND TITLE–ABS–KEY ( ultraso* OR *sonography OR echography )) AND (LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019)) AND (LIMIT-TO (SUBJAREA, "MEDI")) AND (LIMIT-TO (LANGUAGE , "English") OR LIMIT-TO (LANGUAGE , "Spanish"))].
      Google Scholar: [((lung or chest or pulmo* or thora*) and (ultraso* or sonog* or echography)) and (Covid* or SARS* or coronavirus*)].

      Selection of studies

      For this systematic review, all primary articles were included, including case series for more than one patient and case reports (including letters to the editor), in which PU was part of the diagnostic evaluation and/or clinical follow-up and/or as a criterion for discharge of patients with COVID-19 confirmed by RT-PCR. Studies in which modifications had been made to the conventional PU technique were excluded.
      The selection of articles was carried out independently by two investigators (S.P.S., A.C.N.S.). If there was no agreement, a third investigator (J.T.V.) made the decision to include or exclude the study. All studies included in this systematic review were approved by the ethics committee.

      Risk of bias

      Two authors (K.A.L. and V.P.C.) rated the quality of the studies according to the National Institutes of Health Quality Assessment Tool for case series studies.

      Extraction of data

      The data from each study was extracted into a Microsoft Excel database designed for this purpose. Country, type of study, the reason PU was performed, population, type of transducer and evaluation protocol used, PU findings and the qualitative and/or quantitative correlation reported between PU and other imaging techniques (CXR or chest CT) were noted.

      Results

      Search strategy

      The search strategy yielded 949 results; 510 duplicates records were removed. Of 439 records screened, 405 were excluded by title and abstract screening. Of 34 full-text articles assessed for eligibility, 6 articles were excluded, and 28 articles were included in qualitative analysis (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ,
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      ;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yassa M
      • Birol P
      • Mutlu AM
      • Tekin AB
      • Sandal K
      • Tug N.
      Lung ultrasound can influence the clinical treatment of pregnant women With COVID-19.
      ) were included (Fig. 1). The studies were classified as follows: 2 retrospective cohort studies included 150 patients, 1 prospective cohort comprised 31 patients, a cross-sectional study comprised 26 patients, 14 case series that included between 3 and 30 patients and 10 case reports. Twenty-six articles were written in English, 1 in German and 1 in Chinese.
      The 28 articles included a total of 418 patients with COVID-19 confirmed by RT-PCR. One hundred fifty patients were described in two retrospective cohorts, 31 patients in one prospective cohort study, 26 patients in one cross-sectional study, 201 patients in 14 case series studies and 10 patients in 10 case reports studies. PU was performed in the patients in all 28 articles as part of diagnosis, in 20 for clinical follow-up, in 5 as part of a routine procedure and in 5 as an additional criterion to decide whether to discharge the patient from hospital or discharge from the intensive care unit. Patient age was reported by 22 of 28 articles: one study (
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ) included 5 neonates aged 1 to 18 days, and another 21 articles registered 18 children or adolescents between 1 and 17 years and 395 adults. In 24 of 28 articles, the sex of the patients was noted, finding 203 men and 143 women (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ) (Table 1).
      Table 1Characteristics of included articles
      No.Author (country)MotivePopulation N (M|F)Transducer usedProtocolChest X-ray correlation
      Good or superior correlation based on the author's qualitative report; statistical testing was not performed.
      Chest CT correlation
      Good or superior correlation based on the author's qualitative report; statistical testing was not performed.
      Retrospective cohort
      1
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.


      (Italy)
      D, M, DisHospitalized adults in ICU:

      84 (65|19)
      Linear/sectorial12 zonesSuperiorGood
      2
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.


      (Italy)
      D, M, DisHospitalized adults in ICU:

      66 (36|30)
      NRNRNPGood
      Prospective cohort
      3
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      (France)
      D, MHospitalized adults:

      31 (11|20)
      Convex8 zonesNPGood
      Cross-sectional study
      4
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.


      (Italy)
      DHospitalized adults:

      26 (14|12)
      Linear/convex8 zonesNPGood

      r=0.65 (p<0.001)
      Case series
      5
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.


      (China)
      D, MHospitalized adults:

      30 (NR)
      NRNRNPGood
      6
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      (China)
      D, MHospitalized adults:

      29 (18|11)
      Convex12 zonesNPSuperior
      7
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      (Italy)
      D, M, RHospitalized adults:

      22 (NR)
      Linear/convexNRYes, good in 11Yes, good in 16
      8
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      (China)
      DAdults:

      20 (NR)
      NR12 zonesNPGood
      9
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      (China)
      D, MHospitalized adults:

      20 (11|9)
      Linear/convex12 zonesNPGood
      10
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      (China)
      D, MHospitalized adults:

      20 (12|8)
      NRNRNPNP
      11
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      (Italy)
      DHospitalized adults:

      12 (9|3)
      NRNRNPGood
      12
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      (USA)
      D, MHospitalized adults:

      10 (7|3)
      Sectorial6 zonesNPYes, good in 1
      13
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      (Italy)
      D, RHospitalized children:

      10 (6|4)
      Linear/wireless12 zonesYes, good in 2Yes, good in 1
      14Yassa et al. 2020 (Turkey)D, M, DisHospitalized pregnant women:

      8 (0|8)
      Convex14 zones3/8 Good5/8 Good
      15
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      (Italy)
      RHospitalized children:

      8 (5|3)
      NRNRYes, good in 7Good
      16
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      (China)
      D, MHospitalized children:

      5 (3|2)
      NRNRGoodSuperior
      17
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      (Italy)
      D, MHospitalized pregnant women in ICU:

      4 (0|4)
      NRNRYes, good in 2NP
      18
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      (Spain)
      D, MHospitalized adults in UCI: 3 (1|2)Linear/wireless12 zonesGoodGood
      Case reports
      19
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      (USA)
      D, MHospitalized adult:

      1 female
      ConvexNRGoodNP
      20
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      (Italy)
      D, MHospitalized adult:

      1 male
      Convex/wireless12 zonesGoodGood
      21
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      (USA)
      D, MHospitalized adult:

      1 female
      Convex/wireless6 zonesNPNP
      22
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      (China)
      DHospitalized adult:

      1 female
      ConvexNRNPGood
      23
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      (Spain)
      D, M, DisHospitalized adult:

      1 male
      Convex/wireless8 zonesNPNP
      24
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      (Italy)
      DHospitalized pregnancy: 1 femaleConvexNRGoodNP
      25
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      (USA)
      DHospitalized adult:

      1 female
      Convex6 zonesGoodGood
      26
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      (USA)
      D, MHospitalized adult:

      1 male
      Linear6 zonesSuperiorNP
      27
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      (France)
      D, MAdult in ICU: 1 maleNRNRNPGood
      28
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      (Italy)
      D, MHospitalized adult:

      1 male
      ConvexNRGoodGood
      D = diagnosis; M = monitorization; R = routine; Dis = discharge; ICU = intensive care unit; CT = thoracic (chest) tomography; TR = thoracic radiography; NR = no report; NP = not performed.
      low asterisk Good or superior correlation based on the author's qualitative report; statistical testing was not performed.
      Among the patients included, 13 were pregnant with an average gestation of 23.4 wk (standard deviation: 11.5 wk) at the time of diagnosis (
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ; Yassa et al. 2020). It was reported that the 13 fetuses did not present alterations during gestation, and four deliveries were reported with products without infection at birth.

      Characteristics of the PU procedure

      In 20 of the 28 studies, PU was a bedside procedure; in the remaining 8 studies, patients were transferred to a specific area for the procedure. Nineteen articles reported the transducer used; in 17 of these studies, a linear or convex transducer was used (
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020). In 15 of the 28 articles, the ultrasound evaluation protocol used was mentioned. In 7 articles, a protocol of 12 zones was used (
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ); in 4 articles a protocol of 6 zones was used (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ); in 1 article a protocol with 14 zones was used (Yassa et al. 2020); and in 3 articles a protocol of 8 zones was used (
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ).

      Comparison with CXR and chest CT

      Two hundred seventy-seven of 418 patients did not undergo CXR (
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ), including 7 of the 13 pregnant women. Fifty-six of the 418 patients did not undergo chest CT (
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ), including 10 of the 13 pregnant women. Forty-four of the 418 patients underwent neither CXR nor chest CT, being evaluated only with PU and RT-PCR (
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Raffaelli F
      • Tamburrini E
      • Biasucci DG
      • Salvi S
      • Smargiassi A
      • Inchingolo R
      • Scambia G
      • Lanzone A
      • Testa AC
      • Moro F.
      Clinical role of lung ultrasound for diagnosis and monitoring of COVID-19 pneumonia in pregnant women.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ). In the 5 articles that included these 44 patients, the authors did not describe a clinical course different from those of the remaining patients evaluated with CXR and/or chest CT.
      Because of the types of articles found in this systematic review, the global quantitative correlation of PU with CXR and/or chest CT could not be assessed; therefore, we report the qualitative result described by the authors. Of the 14 articles that evaluated the qualitative correlation between PU and CXR findings, 12 considered it good and 2 (including the cohort of 84 patients) reported that PU was superior to CXR (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ). Likewise, of the 20 studies that evaluated the qualitative correlation between PU and chest CT, 18 considered it good and 2 reported that PU was superior to chest CT (
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ) (Table 1). Only the cross-sectional article reported a quantitative correlation between PU and chest CT, indicating that it was good with r = 0.65 and p < 0.001 (
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ).
      In total, considering all procedures performed in studies that used CXR or chest CT (even repeat examinations), we found that PU was performed 18 times more than CXR and 12 times more than chest CT. The cohort of 84 patients reported that PU reduced the use of CXR and chest CT by 31.8% before the use of PU to 3.6% after the use of this procedure (
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ).

      Pulmonary ultrasound findings and their correlation with chest CT findings

      In Table 2 the PU findings are outlined. All articles (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      , 2020b;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ) reported the presence of B-lines: coalescent, multifocal, diffuse, confluent or “white lung.” Alteration of the pleural line was reported in 25 of 28 articles: irregular, thickened, interrupted. Alteration of the pulmonary parenchyma was reported as presence of lobar, multilobar or noduliform subpleural consolidations with bilateral and posterior distribution. The presence of the dynamic air bronchogram was described in 4 studies (
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ). One article did not describe the presence or absence of pulmonary alterations (
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ). One article indicated that there were no alterations to the pulmonary parenchyma (
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ). Pleural effusion was reported in only 1 article (
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ). The presence of pneumothorax was reported in only 1 article (
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ).
      Table 2Results of informed pulmonary ultrasound of COVID-19 patients in included articles
      N
      According to the numeration in Table 1.
      B-LinesPleural lineConsolidation
      Retrospective cohort
      1Yes, multifocal, coalescentNon-sliding, irregularMultilobar, lobar, dynamic air bronchogram
      2Yes, focal and multifocal, diffuseIrregular, interruptedMultilobar
      Prospective cohort
      3Yes, confluentThickenedConsolidated
      Transversal
      4Yes, diffuse, coalescentIrregularMicroconsolidations and consolidations
      Case series
      5Yes, interstitial syndromeNRPresent, lobar, posterior, subpleural, peripheral
      6Interstitial syndromeIrregular, thickenedMultilobar, subpleural, posterior
      7Yes, diffuseIrregularSubpleural, bilateral, posterior
      8Yes, diffuse, bilateralThickened, irregularSubpleural, bilateral, posterior
      9Yes, coalescent, confluentThickened irregularNodular consolidation, bronchogram, patches, bilateral
      10Yes, confluent, diffuseIrregular, InterruptedBilateral, multilobar
      11Yes, diffuseIrregularSubpleural, occasional, bilateral
      12Yes, confluent, white lungIrregularSubpleural, lobar, bilateral
      13White lungIrregularSubpleural, posterior, bilateral
      14Yes, bilateral, coalescentIrregularSubpleural, bilateral, pleural effusion
      15Yes, confluentNRSubpleural
      16Yes, white lungIrregularSmall, subpleural
      17Yes, diffuseIrregularConsolidation, bilateral, posterior
      18Yes, coalescentIrregular, ThickenedLobar, bilateral
      Case reports
      19Yes, posterior, bilateralThickenedBilateral
      20Yes, coalescentNRSubpleural nodular
      21Yes, coalescentIrregularNo
      22Yes, coalescentIrregularSubpleural, present
      23YesIrregularSubpleural, unilateral
      24Yes, white lungThickenedNR
      25Yes, diffuseIrregularPresent
      26Yes, multifocalRegular, thickenedSubcentimetric, lobar, posterior
      27Yes, diffuse and coalescentIrregularMultilobar, bilateral
      28Yes, multifocal and coalescentThickened, non-slidingPneumothorax, dynamic air bronchogram
      NR = no report.
      low asterisk According to the numeration in Table 1.
      Table 3 summarizes the PU findings in the 28 articles (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      , 2020b;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ) included in this rapid systematic review, which have been grouped with respect to the location of the lesions: pleural line, presence of B-lines, lung parenchyma or pleural cavity and its comparison with chest CT lesions caused by COVID-19 (Fig. 2).
      Table 3Pulmonary ultrasound findings and their correlation with thoracic tomography in the diagnosis of pleuroparenchymal disease of COVID-19
      Thoracic tomographyPulmonary ultrasound
      Pleural thickeningThickening and irregularity of the pleural wall
      Subpleural ground-glass opacitiesB-Lines (multifocal, discrete, confluent)
      Reticular interstitial lesionsConfluent B-lines
      Subpleural consolidationSubpleural consolidations with dynamic air bronchogram
      Translobar consolidationTranslobar consolidation
      Rare presence of pleural effusionRare presence of pleural effusion
      Multilobar, basal, posteriorMultilobar, basal, posterior
      Fig 2
      Fig. 2Simplified description of the main lung ultrasound findings by stage of COVID-19 disease.

      Discussion

      Pulmonary ultrasound results

      The PU results are similar and consistent among the different articles included in this systematic review, concur simultaneously with the results of the systematic revisions and narratives (
      • Ai T
      • Yang Z
      • Hou H
      • Zhan C
      • Chen C
      • Lv W
      • Tao Q
      • Sun Z
      • Xia L.
      Correlation of chest CT and RT-PCR testing for Coronavirus Disease 2019 (COVID-19) in China: A report of 1014 cases.
      ;
      • Antúnez-Montes OY
      • Buonsenso D.
      Routine use of point-of-care lung ultrasound during the COVID-19 pandemic [e-pub aheqad of print].
      ;
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Fang Y
      • Zhang H
      • Xie J
      • Lin M
      • Ying L
      • Pang P
      • Ji W
      Sensitivity of chest CT for COVID-19: Comparison to RT-PCR.
      ;
      • Fiala MJ.
      Ultrasound in COVID-19: A timeline of ultrasound findings in relation to CT.
      ;
      • Fraile Gutiérrez V
      • Ayuela Azcárate JM
      • Pérez-Torres D
      • Zapata L
      • Rodríguez Yakushev A
      • Ochagavía A
      Ultrasound in the management of the critically ill patient with SARS-CoV-2 infection (COVID-19): Narrative review.
      ;
      • Mohamed MFH
      • Al-Shokri S
      • Yousaf Z
      • Danjuma M
      • Parambil J
      • Mohamed S
      • Mubasher M
      • Dauleh MM
      • Hasanain B
      • AlKahlout MA
      • Abubeker IY.
      Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: Systematic review and meta-analysis.
      ;
      • Ojha V
      • Mani A
      • Pandey NN
      • Sharma S
      • Kumar S.
      CT in coronavirus disease 2019 (COVID-19): A systematic review of chest CT findings in 4410 adult patients.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ) and correlate qualitatively with the COVID-19 results observed on chest CT (
      • Ai T
      • Yang Z
      • Hou H
      • Zhan C
      • Chen C
      • Lv W
      • Tao Q
      • Sun Z
      • Xia L.
      Correlation of chest CT and RT-PCR testing for Coronavirus Disease 2019 (COVID-19) in China: A report of 1014 cases.
      ;
      • Fang Y
      • Zhang H
      • Xie J
      • Lin M
      • Ying L
      • Pang P
      • Ji W
      Sensitivity of chest CT for COVID-19: Comparison to RT-PCR.
      ;
      • Ojha V
      • Mani A
      • Pandey NN
      • Sharma S
      • Kumar S.
      CT in coronavirus disease 2019 (COVID-19): A systematic review of chest CT findings in 4410 adult patients.
      ;
      • Pan F
      • Ye T
      • Sun P
      • Gui S
      • Liang B
      • Li L
      • Zheng D
      • Wang J
      • Hesketh RL
      • Yang L
      • Zheng C.
      Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).
      ), as summarized in Table 3.

      Characteristics

      Our results indicate that PU has been used at various stages of the disease (diagnosis, follow-up, as an evaluation for discharge and in observation of the resolution of lesions in a progressive manner) in an adequate manner and with benefits for the patient. We included 418 patients, indicating that the use of PU continues to increase in patients with COVID-19; previous reviews have included fewer than 60 patients (
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ), and a recent systematic review with meta-analysis included 122 patients (
      • Mohamed MFH
      • Al-Shokri S
      • Yousaf Z
      • Danjuma M
      • Parambil J
      • Mohamed S
      • Mubasher M
      • Dauleh MM
      • Hasanain B
      • AlKahlout MA
      • Abubeker IY.
      Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: Systematic review and meta-analysis.
      ) although more evidence is required to define the usefulness of PU at each stage.
      The protocol of 12 zones is the most frequently used protocol in the articles reviewed (
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ), including the study of cohorts of 84 patients. It is followed by the protocol of 6 zones (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ). However, these differences in the protocols used did not affect the presence or absence of pathological findings on PU or the way the findings were reported. It might be convenient to propose the use of the 12-zone protocol as it is the most widely used. Also, convex and linear transducers were the most frequently used transducers, which is important because most conventional ultrasound are equipped with these transducers.

      Other aspects of the use of PU for consideration

      PU has other benefits, such as greater availability compared with chest CT and RT-PCR, low cost per examination, ease of access, shorter duration, dynamic and repeated evaluation of pulmonary parenchyma, accessibility to bedridden patients, safety for pregnant women, ease of integration of telemedicine in areas that lack trained specialists and immediate results unlike in RT-PCR (
      • Alkhafaji M
      • Ward T
      • Truong J.
      A case of lung ultrasound findings in a 73-year-old male with COVID-19.
      ;
      • Bar S
      • Lecourtois A
      • Diouf M
      • Goldberg E
      • Bourbon C
      • Arnaud E
      • Domisse L
      • Dupont H
      • Gosset P.
      The association of lung ultrasound images with COVID-19 infection in an emergency room cohort [e-pub ahead of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      , 2020b;
      • Consoli L
      • Bendotti V
      • Cicchinelli S
      • Gaioni F
      • Prandolini P
      • Bettonagli M
      • Terragnoli P.
      2019 novel coronavirus (COVID-19) pneumonia complications: The importance of lung ultrasound [e-pub ahead of print].
      ;
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Denina M
      • Scolfaro C
      • Silvestro E
      • Pruccoli G
      • Mignone F
      • Zoppo M
      • Ramenghi U
      • Garazzino S.
      Lung ultrasound in children with COVID-19.
      ;
      • Duclos G
      • Lopez A
      • Leone M
      • Zieleskiewicz L.
      “No dose” lung ultrasound correlation with “low dose” CT scan for early diagnosis of SARS-CoV-2 pneumonia.
      ;
      • Farrow R
      • Becherer-Bailey G
      • Mantuani D
      • Nagdev A.
      Early Multi-organ point-of-care ultrasound evaluation of respiratory distress during SARS-CoV-2 outbreak: Case report.
      ;
      • Feng XY
      • Tao XW
      • Zeng LK
      • Wang WQ
      • Li G.
      [Application of pulmonary ultrasound in the diagnosis of COVID-19 pneumonia in neonates].
      ;
      • Gargani L
      • Soliman-Aboumarie H
      • Volpicelli G
      • Corradi F
      • Pastore MC
      • Cameli M.
      Why, when, and how to use lung ultrasound during the COVID-19 pandemic: Enthusiasm and caution.
      ;
      • Huang Y
      • Wang S
      • Liu Y
      • Zhang Y
      • Zheng C
      • Zheng Y
      • Zhang C
      • Min W
      • Zhou H
      • Yu M
      • Hu M.
      A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19).
      ;
      • Inchingolo R
      • Smargiassi A
      • Moro F
      • Buonsenso D
      • Salvi S
      • Del Giacomo P
      • Scoppettuolo G
      • Demi L
      • Soldati G
      • Testa AC.
      The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound.
      ;
      • Ippolito D
      • Pecorelli A
      • Maino C
      • Capodaglio C
      • Mariani I
      • Giandola T
      • Gandola D
      • Bianco I
      • Ragusi M
      • Talei Franzesi C
      • Corso R
      • Sironi S
      Diagnostic impact of bedside chest X-ray features of 2019 novel coronavirus in the routine admission at the emergency department: case series from Lombardy region.
      ;
      • Ji L
      • Li Y
      • Cao C
      • Lv Q
      • Xie M.
      Serial bedside lung ultrasonography in a critically ill COVID-19 patient.
      ;
      • Kristensen MS
      • Teoh WH
      • Graumann O
      • Laursen CB.
      Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae.
      ;
      • Lomoro P
      • Verde F
      • Zerboni F
      • Simonetti I
      • Borghi C
      • Fachinetti C
      • Natalizi A
      • Martegani A.
      COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Nouvenne A
      • Zani MD
      • Milanese G
      • Parise A
      • Baciarello M
      • Bignami EG
      • Odone A
      • Sverzellati N
      • Meschi T
      • Ticinesi A.
      lung ultrasound in COVID-19 pneumonia: Correlations with chest CT on hospital admission.
      ;
      • Ojha V
      • Mani A
      • Pandey NN
      • Sharma S
      • Kumar S.
      CT in coronavirus disease 2019 (COVID-19): A systematic review of chest CT findings in 4410 adult patients.
      ;
      • Palmese F
      • Caroli B
      • Graziani A
      • Zanframundo G
      • Del Toro R
      • Sagrini E
      • Cataleta P
      • Domenicali M.
      Daily Evaluation of COVID-19 patients primarily based on lung ultrasound: In times of emergency, it's time to change some paradigms.
      ;
      • Pan F
      • Ye T
      • Sun P
      • Gui S
      • Liang B
      • Li L
      • Zheng D
      • Wang J
      • Hesketh RL
      • Yang L
      • Zheng C.
      Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).
      ;
      • Pecho-Silva S.
      Rol del ultrasonido pulmonar en el diagnóstico de la neumonía por SARS-CoV-2: ¿Alternativa a la escasez de tomógrafos?.
      ;
      • Peng QY
      • Wang XT
      • Zhang LN
      Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Reisinger N
      • Koratala A.
      Lung ultrasound: A valuable tool for the assessment of dialysis patients with COVID-19.
      ;
      • Schiaffino S
      • Tritella S
      • Cozzi A
      • Carriero S
      • Blandi L
      • Ferraris L
      • Sardanelli F.
      Diagnostic performance of chest X-Ray for COVID-19 pneumonia during the SARS-CoV-2 pandemic in Lombardy, Italy.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ;
      • Soldati G
      • Smargiassi A
      • Inchingolo R
      • Buonsenso D
      • Perrone T
      • Briganti DF
      • Perlini S
      • Torri E
      • Mariani A
      • Mossolani EE
      • Tursi F
      • Mento F
      • Demi L
      Is there a role for lung ultrasound during the COVID-19 pandemic?.
      ;
      • Thomas A
      • Haljan G
      • Mitra A.
      Lung ultrasound findings in a 64-year-old woman with COVID-19.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ;
      • Xing C
      • Li Q
      • Du H
      • Kang W
      • Lian J
      • Yuan L.
      Lung ultrasound findings in patients with COVID-19 pneumonia.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ; Yassa et al. 2020;
      • Yasukawa K
      • Minami T.
      Point-of-care lung ultrasound findings in patients with COVID-19 pneumonia.
      ;).
      With respect to the learning process, the authors of some included articles mentioned that its implementation is short and therefore feasible (
      • Ippolito D
      • Pecorelli A
      • Maino C
      • Capodaglio C
      • Mariani I
      • Giandola T
      • Gandola D
      • Bianco I
      • Ragusi M
      • Talei Franzesi C
      • Corso R
      • Sironi S
      Diagnostic impact of bedside chest X-ray features of 2019 novel coronavirus in the routine admission at the emergency department: case series from Lombardy region.
      ;
      • Lu W
      • Zhang S
      • Chen B
      • Chen J
      • Xian J
      • Lin Y
      • Shan H
      • Su ZZ.
      A clinical study of noninvasive assessment of lung lesions in patients with coronavirus disease-19 (COVID-19) by bedside ultrasound.
      ;
      • Mongodi S
      • Orlando A
      • Arisi E
      • Tavazzi G
      • Santangelo E
      • Caneva L
      • Pozzi M
      • Pariani E
      • Bettini G
      • Maggio G
      • Perlini S
      • Preda L
      • Iotti GA
      • Mojoli F.
      Lung ultrasound in patients with acute respiratory failure reduces conventional imaging and health care provider exposure to COVID-19.
      ;
      • Ojha V
      • Mani A
      • Pandey NN
      • Sharma S
      • Kumar S.
      CT in coronavirus disease 2019 (COVID-19): A systematic review of chest CT findings in 4410 adult patients.
      ;
      • Pan F
      • Ye T
      • Sun P
      • Gui S
      • Liang B
      • Li L
      • Zheng D
      • Wang J
      • Hesketh RL
      • Yang L
      • Zheng C.
      Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).
      ;
      • Pecho-Silva S.
      Rol del ultrasonido pulmonar en el diagnóstico de la neumonía por SARS-CoV-2: ¿Alternativa a la escasez de tomógrafos?.
      ;
      • Schiaffino S
      • Tritella S
      • Cozzi A
      • Carriero S
      • Blandi L
      • Ferraris L
      • Sardanelli F.
      Diagnostic performance of chest X-Ray for COVID-19 pneumonia during the SARS-CoV-2 pandemic in Lombardy, Italy.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ;
      • Yang Y
      • Huang Y
      • Gao F
      • Yuan L
      • Wang Z.
      Lung ultrasonography versus chest CT in COVID-19 pneumonia: A two-centered retrospective comparison study from China.
      ). Also beneficial in PU is that cleaning and disinfection of the equipment are much easier and faster for PU than for CXR or chest CT equipment, and the same disinfection protocols are used.
      In addition, portable PU equipment is becoming less expensive and has increasing resolution, allowing the transmission of images via Wi-Fi or Bluetooth, so only a single healthcare worker would have to approach the patient to perform the procedure; the rest of the healthcare team can receive the images outside the patient's isolation room without exposing themselves to potential contagion (
      • Antúnez-Montes OY
      • Buonsenso D.
      Routine use of point-of-care lung ultrasound during the COVID-19 pandemic [e-pub aheqad of print].
      ;
      • Buonsenso D
      • Piano A
      • Raffaelli F
      • Bonadia N
      • de Gaetano Donati K
      • Franceschi F.
      Point-of-care lung ultrasound findings in novel coronavirus disease-19 pnemoniae: A case report and potential applications during COVID-19 outbreak.
      ;
      • Fraile Gutiérrez V
      • Ayuela Azcárate JM
      • Pérez-Torres D
      • Zapata L
      • Rodríguez Yakushev A
      • Ochagavía A
      Ultrasound in the management of the critically ill patient with SARS-CoV-2 infection (COVID-19): Narrative review.
      ;
      • Gargani L
      • Soliman-Aboumarie H
      • Volpicelli G
      • Corradi F
      • Pastore MC
      • Cameli M.
      Why, when, and how to use lung ultrasound during the COVID-19 pandemic: Enthusiasm and caution.
      ;
      • Mohamed MFH
      • Al-Shokri S
      • Yousaf Z
      • Danjuma M
      • Parambil J
      • Mohamed S
      • Mubasher M
      • Dauleh MM
      • Hasanain B
      • AlKahlout MA
      • Abubeker IY.
      Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: Systematic review and meta-analysis.
      ;
      • Musolino AM
      • Supino MC
      • Buonsenso D
      • Ferro V
      • Valentini P
      • Magistrelli A
      • Lombardi MH
      • Romani L
      • D'Argenio P
      • Campana A
      • Lung Roman
      Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung ultrasound in children with COVID-19: Preliminary findings.
      ;
      • Shokoohi H
      • Duggan NM
      • García-de-Casasola Sánchez G
      • Torres-Arrese M
      • Tung-Chen Y.
      Lung ultrasound monitoring in patients with COVID-19 on home isolation.
      ;
      • Tung-Chen Y.
      Lung ultrasound in the monitoring of COVID-19 infection.
      ). To date, no contraindications to the use of PU or complications associated with its use have been described.

      What does the literature say about PU in COVID-19?

      So far, PU is a useful tool in diagnosis and monitoring and as a criterion for hospital and ICU discharge for patients with COVID-19. To date, no contraindications to the use of the PU or any complications from its use have been described. PU findings in the different articles were similar, correlated qualitatively well with the tomographic findings and were better than the X-ray findings in patients with COVID-19. PU could, in select cases, replace chest radiography and/or tomography in the diagnosis and follow-up of patients with COVID-19 (
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ).

      Findings from this study

      This review involved the largest number of patients with COVID-19 evaluated with PU to date. PU findings of multifocal, multilobar, subpleural, posterior alterations of the pleural line of the coalescent, irregular, interrupted, thickened type, together with alterations of the pulmonary parenchyma of multilobar or lobar distribution, with dynamic air bronchogram, are frequent findings and consistent with COVID-19 and aid in diagnosis, follow-up and evaluation of response to treatment and as criteria for discharge from the intensive care unit or hospital. PU could replace chest-x ray and could reduce exposure of patients to ionizing radiation and displacement of patients from their rooms, thus exposing fewer staff and other patients to the intranosocomial transmissibility of COVID-19.

      Suggested acquisition protocol

      • Use convex or linear transducers. The latter are preferable to study the detail of the pleural and subpleural alterations.
      • Use a single-focal-point or multifocusing modality and set the focal point on the pleural line.
      • Preferably, scans need to be intercostal to cover the widest surface possible with a single scan.
      • Evaluate the presence of the artifactual patterns in multiple areas and bilaterally to study the extent of lung surface affected.
      • Ideally, 12 areas in total should be evaluated: anterior midclavicular upper and lower on the right and the left; posterior paraspinal (apical, medial and basal), right and left; and lateral axillary (medial), right and left.

      Limitations

      Some of the limitations of this systematic review have to do with the quality of the evidence that comes from only two retrospective cohort studies, one from a prospective cohort and one from a cross-sectional cohort, and letters to the editor, case series and case reports. Another limitation is the different evaluation protocols used to perform PU. A final limitation is that PU does not allow the detection of lesions that are not subpleural or peripheral; however, this would also be of little relevance as COVID-19 lesions are usually subpleural or peripheral and therefore evaluable with PU (
      • Convissar DL
      • Gibson LE
      • Berra L
      • Bittner EA
      • Chang MG.
      Application of lung ultrasound during the COVID-19 pandemic: A narrative review.
      ;
      • Mohamed MFH
      • Al-Shokri S
      • Yousaf Z
      • Danjuma M
      • Parambil J
      • Mohamed S
      • Mubasher M
      • Dauleh MM
      • Hasanain B
      • AlKahlout MA
      • Abubeker IY.
      Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: Systematic review and meta-analysis.
      ;
      • Poggiali E
      • Dacrema A
      • Bastoni D
      • Tinelli V
      • Demichele E
      • Mateo Ramos P
      • Marcianò T
      • Silva M
      • Vercelli A
      • Magnacavallo A
      Can lung US help critical care clinicians in the early diagnosis of novel coronavirus (COVID-19) pneumonia?.
      ;
      • Smith MJ
      • Hayward SA
      • Innes SM
      • Miller ASC.
      Point-of-care lung ultrasound in patients with COVID-19—A narrative review.
      ;
      • Soldati G
      • Smargiassi A
      • Inchingolo R
      • Buonsenso D
      • Perrone T
      • Briganti DF
      • Perlini S
      • Torri E
      • Mariani A
      • Mossolani EE
      • Tursi F
      • Mento F
      • Demi L
      Is there a role for lung ultrasound during the COVID-19 pandemic?.
      ).
      The studies found indicate more experience with the use of PU in patients with COVID-19, even in pregnant women and children, is accumulating. In addition, they report adequate sensitivity and specificity for the diagnosis of COVID-19, and no articles have been published that have found that PU is not useful or that it is harmful to the patient. This suggests that PU is an advantageous tool. However, studies of higher methodological quality are required to corroborate the current findings.

      Acknowledgements

      This research has not received specific funding from public sector agencies, the commercial sector or non-profit organizations.

      Conflict of interest disclosure

      The authors declare no conflicts of interest.

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