Comparison of lung ultrasound scoring systems for the prognosis of COVID-19 in the emergency department: An international prospective cohort study.

Background	Peter J. Snelling et al. , published in the Australasian Journal of Ultrasound in Medicine in 2023, aimed to evaluate the prognostic value of various lung ultrasound (LUS) scoring systems in predicting clinical outcomes for COVID-19 patients.
Authors	Snelling PJ, Jones P, Connolly R, Jelic T, Mirsch D, Myslik F, Phillips L, Blecher G; COVID LUS Study Group.
Journal	Australas J Ultrasound Med. 2023 Oct 29;27(2):75-88. PMID: 38784699; PMCID: PMC11109992.
Methods	This international, multicenter, prospective, observational cohort study included patients presenting to the emergency department (ED) with suspected COVID-19 who were subsequently admitted with confirmed disease. LUS was performed, and patients were followed for outcomes including intubation, ICU admission, or death. Four LUS scoring systems were analyzed and applied retrospectively to the patient data: de Alencar score, a 12-zone protocol (2) CLUE score, a 12-zone protocol (3) Ji score, a 12-zone protocol with lung including pleural findings (4) Tung-Chen score, a 11-zone protocol (5)
Results	129 patients were included in the study, with 24 (18.6%) meeting the composite primary endpoint. No significant association was found between any of the LUS scores and the primary composite outcome (intubation, ICU admission, or death). Odds ratios for the scores ranged from 1.02 to 1.04, with p-values indicating no statistical significance.
Discussion	The lack of association between lung ultrasound (LUS) severity scores and patient outcomes might be attributable to several factors related to changes in the COVID-19 pandemic scenario. These factors include variations in patient demographics, such as age and comorbidities, shifts in disease prevalence and characteristics over time, and differences in healthcare system responses and resources. In particular, changes in virulence as well as increased vaccination rated might have influenced the predictive value of the investigated scores. Additionally, the study may have been underpowered to detect weaker associations due to a smaller sample size than initially intended, which could limit the ability to identify subtle prognostic indicators. However, subtle prognostic indicator might also be of limited clinical relevance. Moreover, other imaging modalities like X-rays and CT scans, which are typically more detailed, also did not demonstrate prognostic value in this cohort. This suggests that the challenges in prognostication are not limited to LUS but extend to imaging techniques in general within this context. Specifically, LUS severity scores failed to effectively predict critical outcomes such as the need for invasive ventilation, ICU admission, or death among COVID-19 patients in this international cohort. The authors emphasize that further research is crucial to establish standardized LUS scoring systems. Such systems would need to be validated and refined to ensure accuracy and reliability. Once developed, these standardized scoring systems should be integrated into clinical management pathways for respiratory viral diseases, enhancing the ability to make informed clinical decisions based on LUS findings. This study underscores the evolving nature of the COVID-19 pandemic and the inherent challenges in using LUS scores for prognostication in a rapidly changing clinical landscape. The variability in the disease’s impact and the healthcare system’s response complicates the establishment of reliable prognostic tools. Therefore, ongoing research and adaptation are essential to improve the utility of LUS and other imaging modalities in managing COVID-19 and potentially other respiratory viral diseases in the future.
Link (DOI)	https://doi.org/10.1002/ajum.12364
Ultrasound speciality	CEUS, Cervical Lymphadenopathy
References	de Alencar JCG, Marchini JFM, Marino LO, da Costa Ribeiro SC, Bueno CG, da Cunha VP, et al. Lung ultrasound score predicts outcomes in COVID-19 patients admitted to the emergency department. Ann Intensive Care 2021; 11(1): 6. Manivel V, Lesnewski A, Shamim S, Carbonatto G, Govindan T. CLUE: COVID-19 lung ultrasound in emergency department. Emerg Med Australas 2020; 32(4): 694–6. Ji L, Cao C, Gao Y, Zhang W, Xie Y, Duan Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care 2020; 24(1): 700. Tung-Chen Y, Gil-Rodrigo A, Algora-Martin A, Llamas-Fuentes R, Rodr ıguez-Fuertes P, Mar ın-Baselga R, et al. The lung ultrasound “rule of 7” in the prognosis of COVID-19 patients: results from a prospective multicentric study. Med Clin (Barc) 2022; 159(1):19–26.

Short-Review by Prof. Dr Julian Kuenzel; Dr Helmut Prosch:

Strength:

Prospective international, multicenter, prospective, observational cohort study

Head-to-head comparison of four different scoring systems

Weaknesses:

Underpowered

Differential diagnosis of cervical lymphadenopathy: Integration of postvascular phase of contrast-enhanced ultrasound and predictive nomogram model

Comparison of lung ultrasound scoring systems for the prognosis of COVID-19 in the emergency department: An international prospective cohort study.

Snelling PJ, Jones P, Connolly R, Jelic T, Mirsch D, Myslik F, Phillips L, Blecher G; COVID LUS Study Group