Research Question:

How successful is Lung Ultrasound (LUS) in accurately diagnosing critically ill COVID-19 patients, and how effective is LUS in managing them?

Research Aim:

This systematic review aims to provide a robust analysis in determining the efficacy of LUS in diagnosing and managing critically ill COVID-19 patients.

Research Objectives:

To compare various radiographic features of COVID-19 from ordinary pneumonia as a baseline.
To evaluate the diagnostic accuracy (specificity and sensitivity) of LUS in detecting COVID-19 in critically ill patients.
To explore the effectiveness of LUS in managing critically ill COVID-19 patients.

Brief summary of proposed study: Be concise and use the correct research terminologies so that the reader can follow what you propose to study and how this will be achieved.

COVID-19 is a transmissible disease caused by the SARS-CoV-2 virus infecting over 100 million people worldwide. The symptoms of COVID-19 may vary from mild fever or cough to serious shortness of breath or chest pain. Hence, early diagnosis and timely intervention are essential to prevent and reduce cases from advancing to a chronic and critical state.

Severe cases of COVID-19 are usually presented with symptoms of serious pneumonia and/or acute respiratory distress syndrome (ARDS). Computed tomography (CT) has been used for first-line investigation while reverse transcription polymerase chain reaction (RT-PCR) is considered the gold standard for the diagnosis of COVID-19 (Jackson et al., 2020).

However, CT scans are challenging for infection control and characterised by high radiation exposure (Allinovi et al., 2020). Meanwhile, there is often a delay on producing RT-PCR results. Ultrasound, on the other hand, poses no radiation threat to patients and can be operated as a mobile handheld instrument to perform LUS conveniently.

Ultrasound minimises radiation exposure to staff as well as reduces patient movement as it allows bedside sonography to be carried out, making it suitable for diverse medical conditions. Moreover, studies have proven that LUS has comparable sensitivity and specificity to CT scans in characterising moderate to severe COVID-19 cases. Therefore, LUS has the potential to allow for the accurate diagnosis and efficient management of patients displaying severe COVID-19 symptoms.

Hence, to achieve the objectives, relevant and up-to-date articles that display ample information on LUS usability on COVID-19 diagnosis and management will be sourced. The articles will be accessed and filtered using keywords in databases such as PubMed and ScienceDirect. The results will help the radiology department improve its strategies for diagnosing and managing COVID-19 patients.

Referenced literature review: This must be a concise underpinning for the research project showing a balanced view of the evidence in the literature that your research will contribute further knowledge to.

The prevalence of COVID-19 disease has advanced globally since early 2020. The World Health Organisation (WHO) labelled the outbreak as a pandemic infection which mainly manifested as mild signs of pneumonia (World Health Organisation, 2019).

However, COVID-19 is also deemed a life-threatening virus causing severe pneumonia in infected patients, potentially evolving into respiratory failure and death due to involvement of both lungs (European Society of Radiology, 2021).

According to WHO, COVID-19 is primarily spread via the droplet route from an infected person’s mouth or nose in tiny liquid molecules when they cough, sneeze, or speak (World Health Organisation, 2019). The extensive and rapid spread of COVID-19 has placed a massive strain on the healthcare system, making this infection a severe health emergency requiring prompt diagnosis and early interventions.

There are several diagnostic pathways for COVID-19 and one of which is LUS. LUS imaging has been a topic of interest by researchers and medical practitioners for diagnosing and managing severe COVID-19, as early findings of the tool’s sensitivity and accuracy have been promising.

Specificity and sensitivity are two vital indicators of test accuracy that enable healthcare professionals to specify the appropriateness of the diagnostic tool (Shreffler & Huecker, 2022). Studies have shown the applicability and range of the LUS in detecting pulmonary alterations and irregularities recognised as a sign of COVID-19 infection. Hence, this research would like to analyse the efficacy of LUS in diagnosing and managing severely ill COVID-19 patients.

Diverse research protocols were utilised to examine the efficacy of LUS in diagnosing critically ill COVID-19 patients. Dargent et al. (2021), Spiedel et al. (2020), and Tan et al. (2020) adopted a 12-zone examination protocol in which the lung was divided into two sides by the anterior and posterior axillary lines, which are further divided into three areas: anterior, lateral, and posterior.

Dargent et al. (2021) and Spiedel et al. (2020) used the LUS scoring system in which the points recorded for B-Lines and pleural thickening are the same. Meanwhile, Tan et al. (2020) used a modified LUS scoring system which provides an extensive scoring range for B-Line and pleural thickening. Conversely, Gibbons et al. (2021) adopted a predetermined standard LUS protocol with a recording time of 6 seconds for each view performed.

Despite the protocols’ differences, the outcomes produced across the studies were similar. Spiedel et al. (2020) and Gibbons et al. (2021) reported that LUS managed to confirm COVID-19 cases in adults with clinical signs and symptoms of the virus. Both studies investigated LUS scans for abnormalities in consolidations, B-lines, and pleural lines in multiple pulmonary zones, similar to viral pneumonia. Gibbons et al. (2021) reported that B-line and irregular pleural line was observed in every LUS image, which increased the specificity and sensitivity to 66.7% and 32.5%, respectively, indicating a better diagnosis of viral pneumonia.

Similarly, Spiedel et al. (2020) reported high sensitivity and specificity values for LUS, standing at 91% and 76%, respectively. Of 10 patients who were accurately diagnosed with COVID-19, 45% were detected with irregular pleural lines, and 24% were noticed with B-lines with more than 3 per intercostal space. Thus, proposing that both studies displayed exceptional predictive characteristics of COVID-19 from mild to severe symptoms.

Additionally, managing patients with severe conditions are plausible given the efficiency of LUS imaging in monitoring the advancement of the disease based on the variations in the LUS score. The LUS score can be used to depict the severity of the infection prompted by ARDS.

Findings show that the value of LUS scores significantly increases with pulmonary complications (Dargent et al., 2021). Besides, the LUS scoring system distinguishes moderate from severely infected COVID-19 patients as the sonographic features for severely infected patients were more extensive, indicating a higher LUS score (Tan et al., 2020). Hence the procedure can monitor severe cases and allow patients to receive early medical treatment.

The LUS also offers practical and medical benefits in managing critically ill COVID-19 patients. Regarding practicality, Speidel et al. (2020) pointed out that LUS is widely available in most hospitals and is highly accessible for patients requiring COVID-19 testing or monitoring, especially for critical cases. Moreover, the equipment is inexpensive, and the machine’s portability is suitable for remote testing and analysis.

It also allows it to be quickly disinfected, providing a clear advantage given the high transmission of COVID-19 (Speidel et al., 2020). Correspondingly, LUS benefit most people in the first week after COVID-19 ARDS diagnosis to detect the aggravation of the disease allowing medical practitioners to manage COVID-19 infection efficiently (Dargent et al., 2021).

In summary, LUS has the potential for accurate COVID-19 diagnosis and regular monitoring, but standardisation and image analysis training seem essential. Studies mentioned above showed the application of LUS in various settings, demonstrating the feasibility of daily LUS assessment for seriously ill COVID-19 patients.

Detail the proposed research approach/method: Give a concise, but clear and detailed, account of all aspects of the proposed methodology in chronological order. Include details of all data collection and plans for data analysis. Include a time plan in the appendix that will show how you will achieve this research study in the time allowed.

Systematic research following a strategy will be applied to obtain appropriate materials. Bibliographic databases mostly comprised of peer-reviewed medical research, namely Pubmed and ScienceDirect, will be used to find electronic literature relevant to the proposed study. The keywords “lung ultrasound,” “diagnosis,” “management,” “COVID-19”, and “seriously ill” were combined with synonymous terms such as “chest ultrasound”, “sonography”, “detection”, and “critically ill”, in addition with the usage of Boolean operators, wildcards and truncations to increase the efficiency of filtering the results.

The review will consist of quantitative and semi-qualitative research literature from the past five years to ensure up-to-date information is included. On the other hand, to ensure relevancy and credibility of data collated, non-English publications, practice literature and publication materials with relatively small sample sizes for quantitative experiments will be excluded.

In addition, initially selected studies will be critically appraised through Caldwell et al. (2011) framework. The critique framework, made applicable for quantitative and qualitative analyses, considers the quality of the experimental design and results. Each study will be reviewed through the framework to screen credible sources.

Data will be extracted from the final set of references and then summarised in a template with basic research information. Collated data will also include protocols and technical specifications, image analysis methods, diagnostic tests, study limitations, recorded sensitivities, and specificities, LUSS and other variables.

To fulfil the research objectives, a robust discussion on various LUS techniques and image analysis from existing studies will be presented to diagnose and manage COVID-19. The LUS will be comprehensively evaluated through specificities and sensitivities in diagnosing patients.

Lastly, the strength and weaknesses of the collated data will be weighed and considered in validating the efficacy of LUS for identifying severe COVID-19 complications. The research time plan will be presented in the appendix.

Outline the justification for the work and explain the benefit to radiography: Why the work is important and what will its impact be? Outline specific deficiencies or issues in published literature and how your study addresses them.

The global persistence of COVID-19 and the severity of patient conditions warrant a systematic study of LUS as a diagnostic tool for similar cases of chest pathologies. Clinical analyses and findings on LUS were diverse; hence, comprehensive, and organised research may show the procedure’s credibility and reliability in diagnosing and managing extreme cases.

Furthermore, a systematic review may critically discuss issues and highlight the need for standard protocols recognised by the medical community. With the presumed efficacy of LUS, the demand for cost-effective radiography testing and monitoring may be addressed.

The study also seeks to explore areas for improvements that may aid future research on the medical and health economic gains of LUS.

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