The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease

Home Isolation, Outreach Criteria, and Early Medical Rescue

Part of the societal problem with our response to COVID-19 has been the perception that it is an “old persons” or “sick persons” disease. This was partially vindicated by early reports out of Wuhan, China, that noted that factors associated with progression to severe COVID-19 pneumonia were advanced age, smoking history, low albumin, and male gender, with smoking having an odd's ratio of 14 for severe disease progression. ¹⁴ However, it is readily becoming apparent that this is not the case, and many of those requiring prolonged critical care are young and otherwise healthy. Statistically though, young healthy people with previously healthy lungs are still at low risk for progression to severe life-threatening disease and most will experience only mild symptoms and recover by self-isolating at home. ¹⁵ Nacoti et al., writing during the midst of their catastrophe in Lombardy, stated that the key to avoid tragedies elsewhere and in the future would be a massive deployment of outreach resources to focus on community-centered care rather than relying on hospital-based care. ² We recognize, however, that such an approach will require being able to recognize those isolated patients who are at risk of deterioration, and “rescuing” or “safety netting” them quickly with an aggressive and comprehensive response. ¹⁵

Lung Ultrasound as a Potential Remote Diagnostic Tool Protecting Health Care Providers

A practical question regarding recommending home isolation of patients, however, is how to identify patients before clinical deterioration? Early chest computed tomography (CT) has been suggested as a screening tool for suspected COVID-19 patients with better sensitivity than polymerase chain reaction. ¹⁶ Chest CT is clearly impractical for home-isolated patients, notwithstanding the logistics there would be unacceptable risks associated with transporting and exposing such patients to all those involved in actually performing a standard CT scan. We thus propose that simple off-the-shelf telemedical self-assessment technology might be supplied to self-isolated and/or quarantined individuals with normal lungs who are at risk for progressive clinical decline to severe acute respiratory distress and death. Owing to the fact that COVID-19 typically presents as a diffuse interstitial bilateral pneumonia mainly in the lung periphery, ^17,18 lung ultrasound examinations, such as the extended focused assessment with sonography for trauma, ¹⁹ may be able to quickly and remotely identify those at risk of clinical deterioration to severe pneumonia at an early stage of illness. ^{20 –23} Lung ultrasound may be positive even before polymerase chain reaction testing. ²⁴ Lung ultrasound, by imaging between the ribs and focusing on the pleural interface, has shown comparable results with chest CT with markedly reduced logistical challenges, ²⁰ sparing the time, effort, and potential exposure of medical providers. Realistically, regardless of any degree of personal protective equipment utilized, the safest medical interaction from a public health standpoint is one that is completely remote, with no physical contact.

Sonographically, disease progression from normal lungs to a simple alveolar-interstitial pattern can be seen by the appearance of single or confluent vertical artifacts (B-lines) or confluent vertical artifacts. ²³ This is an ultrasound syndrome believed to correlate with thickening of the subpleural interlobular septa and increased extravascular lung water producing the comet tail reverberation artifact. ²⁵ This may be chronic or acute, involving conditions such as infiltrative lung diseases, pulmonary edema, acute respiratory distress syndrome, or interstitial pneumonia. ²⁶ Often sonographic findings are apparent before those seen on plain radiography. ²⁷ Previous study has demonstrated that with remote guidance, nonexpert point of care providers can be guided to place an inexpensive ultrasound probe onto the chest to assess the visceral–parietal pleural surface ( Fig. 1, Supplementary Video S1). ^{28 –31} We thus suggest that assessment of this pleural surface may aid in the early diagnosis of COVID-19. If this is proven to be true by continued research, mentored lung examinations could be performed by the patient themselves analogous to an astronaut being guided to perform a self-examination, or by a family member who is isolated with them. Current recommendations for suspected COVID-19 patients are to use small probes such as wireless probes that are more easily sterilized or protected. ³² With simple off-the-shelf informatics, we also propose that the mentoring expert (or panel of experts) could be anywhere in the world, ^4,12,33 assessing patients as needed, even if they were themselves isolated or in quarantine. Presumably, expert reassurance from a human voice would be reassuring to naturally anxious individuals, recognizing that the healthy but panicked survivors are typically the first wave to potentially overwhelm medical resources in any disaster scenario.

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Fig. 1.

Still image of EFAST pleural interface depiction provided by a 7-year-old child examining his grandmother under real-time remote telementored guidance. EFAST, Extended Focused Assessment with Sonography for Trauma.