COVID & The Lung (Ultrasound)

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The Pre-brief

Lung ultrasound can aid in the risk stratification, early diagnosis, and management of respiratory failure from COVID-19. For some basics on how to perform a lung ultrasound please review Segun’s post on how to obtain BAT views. 

There are 2 different phenotypes for COVID-19 ARDS patients. Are there 2 different lung ultrasound patterns as well? 

Two different types of phenotypes have been described.

  • The L-type has preserved lung compliance with disproportionate hypoxia. CT chest shows  typical peripheral ground glass opacities. Lung ultrasound typically shows B lines with some adjacent spared areas with an A line pattern. Some also debate that many of these patients have a “silent hypoxemia” (preserved compliance state in the early phase of respiratory failure but eventually progress to a more typical ARDS picture with low compliance). 
  •  The H-type is a more typical ARDS. CT shows dense consolidations with lung ultrasound showing loss of aeration of the lower lobes. 

Let’s see some images and talk about some COVID-19 cases 

Image 1. Lung ultrasound/anterior lung. 43 year old with COVID-19 respiratory failure requiring HFNC. CT scan showed diffuse peripheral ground-glass opacities. Image 1 is a lung ultrasound image showing an irregular/thick pleural line with confluent B lines with adjacent areas of the spared lung.  (sometimes these spared areas can have a A-line pattern ).

Image 2. Lung ultrasound anterior lung. 73-year-old male with COVID- ARDS. CT scan chest showed diffuse ground-glass opacities. Image 2 is a lung ultrasound image showing an interrupted irregular pleural line with sub-pleural small consolidations and associated B lines.  This is commonly seen in COVID patents especially in patients with ARDS.  

Image 3. Lung ultrasound at the posterolateral alveolar/pleural syndrome  (PLAPS) point. The “Tissue-like” sign can be appreciated. A tissue-like sign is a representation of complete loss of aeration to the point that the sonographic appearance of the lung matches that of other tissues such as the liver.  Air bronchograms and a lung pulse can help differentiate viral pneumonia vs. atelectasis. Based on this lung ultrasound finding, APRV was initiated leading to gradual improvement in lung recruitment and oxygenation.


So are there different lung ultrasound findings for the different phenotypes of COVID patients? 

  • Confluent B lines with adjacent areas of the spared lung with an A-line pattern. These findings correlate with ground glass opacities on the CT chest. These are seen in both “L” and “H” phenotypes.
  • Subpleural consolidations and irregular pleural lines are commonly seen in both phenotypes of COVID-19 ARDS patients. 
  • Dense consolidation with tissue-like sign and PLAPS can be seen in COVID 19 patients. Some of these patients who have atelectasis may benefit from a ventilator strategy with higher mean airway pressures.  This is seen more in the “H-type” COVID phenotype.
  • Large pleural effusions are atypical for COVID-19 patients. 

So for which patient should I perform a lung ultrasound? Is there a situation in which I should not perform a lung ultrasound? 

  •  Lung ultrasound ideally should be performed if it would change your clinical management or to answer a clinical question. 
  •  In the ED, if you have decided to admit a patient to the medicine floor or the ICU based on your clinical assessment, then a thoracic ultrasound should not change that decision. A patient with typical lung ultrasound findings may be at a higher risk for worsening disease so it may help with risk stratification. 
  • On the medicine floor, patients with typical lung ultrasound signs may be at a higher risk for worsening disease.
  • In the ICU, lung ultrasound can help guide ventilator management. A patient with typical loss of aeration of the lower lobes (i.e. atelectasis ) may benefit from a ventilator strategy with higher mean airway pressures ( image 3 ).  

Glossary of Terms

  • ARDS- Acute Respiratory Distress Syndrome 
  • PLAPS- Postero Lateral Alveolar Pleural syndrome 
  • APRV- Airway Pressure Release Ventilation


  1. Jackson K, Butler R, Aujayeb ALung ultrasound in the COVID-19 pandemicPostgraduate Medical Journal 2021;97:34-39.
  2. Karagöz A, Sağlam C, Demirbaş HB, Korkut S, Ünlüer EE. Accuracy of Bedside Lung Ultrasound as a Rapid Triage Tool for Suspected Covid-19 Cases. Ultrasound Q. 2020 Dec;36(4):339-344. doi: 10.1097/RUQ.0000000000000530. PMID: 32976318.


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