Using echocardiography to guide the treatment of novel coronavirus pneumonia

According to the pathophysiological mechanism of shock, it can be divided into 4 types: distributed shock, cardiogenic shock, hypovolemic shock, and obstructive shock. Critical ultrasonography is of great significance in fast identifying the types of shock and guide hemodynamic management. Since the focused cardiac ultrasound (FOCUS) was proposed in 2010 [2], many different types of FOCUS exams for rapid evaluation of emergency or ICU patients have been introduced, including the focus-assessed transthoracic echocardiography (FATE) advanced FATE protocol [3], fluid administration limited by lung sonography (FALLS) protocol [4], and critical care chest ultrasonic examination (CCUE) protocol [5]. In COVID-19 patients, the most common types of shock are septic shock and cardiogenic shock; however, we still need to exclude obstructive shock (massive pericardial effusion, right heart collapse, heart swing, RV enlargement and “D sign,” tricuspid valve regurgitation, pulmonary artery or deep vein thrombosis, etc.) and hypovolemic shock (decrease of CO, “papillary muscle kissing sign,” IVC collapse and high respiratory variability, etc.) first. Further, we assess whether there are signs supporting cardiogenic shock (enlargement of the heart, segmental or diffuse contraction abnormalities, IVC dilation, B lines in the lungs and pleural effusion, etc.). If the above three kinds of shock are excluded, then we may consider distributed shock according to clinical history and laboratory tests.

Novel coronavirus pneumonia may cause the increase in pulmonary vascular resistance due to hypoxia, pulmonary vasospasm, hypercapnia, and inflammation, which further affect the right heart function. Mechanical ventilation itself, especially when lung protective ventilation is not implemented properly, will further increase pulmonary artery pressure and aggravate right heart dysfunction. Right heart dysfunction can be detected by echocardiography, therefore providing important information for circulatory and respiratory management strategies in patients with nCoV pneumonia.

Novel coronavirus pneumonia is different from severe acute respiratory syndrome (SARS) in that severe lung injury occurs at the beginning. Some critically ill patients suffer from multiple organ failure, which worsen dramatically in the late stage of disease. It could be a kind of like the “inflammatory storm” with uncontrolled inflammatory reaction in the body. During hypoxia, respiratory distress, intense stress status, and inflammation, the left heart may go through the following abnormalities: segmental dyskinesia, overall hyperdynamic, and diffuse cardiodepression. Diffuse cardiodepression often occurs during lethal hypoxia, in the process of intubation, or after cardiopulmonary resuscitation. The long term of anoxia and inflammation should also be considered. The circulatory failure is often caused by diffuse cardiodepression after arrest and the decrease of vascular tension caused by lactic acidosis. Sepsis or myocardial infarction can also lead to these changes. Left heart function can be evaluated by rapid qualitative and quantitative methods using echocardiography. Critical ultrasonography can also provide etiological evaluation and treatment guidance for patients with systolic dysfunction.

As an important part of critical ultrasonography, echocardiography is a useful tool for the fast screen of circulatory status, identifying the types of shock, monitoring during the respiratory and hemodynamic management, and guiding the treatment of nCoV pneumonia patients, which is especially feasible, convenient, and advantageous in critically ill patients.