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Lung ultrasound in ruling out COVID-19 pneumonia in the ED: a multicentre prospective sensitivity study
  1. Carmine Cristiano Di Gioia1,
  2. Nicola Artusi1,
  3. Giovanni Xotta2,
  4. Marco Bonsano3,
  5. Ugo Giulio Sisto1,
  6. Marzia Tecchiolli1,
  7. Daniele Orso4,
  8. Franco Cominotto1,
  9. Giulia Amore5,
  10. Stefano Meduri6,
  11. Roberto Copetti5
  1. 1 Department of Emergency Medicine, Trieste University Integrated Healthcare Company, Trieste, Friuli-Venezia Giulia, Italy
  2. 2 Department of Emergency Medicine, University of Verona, Verona, Veneto, Italy
  3. 3 Department of Emergency Medicine, Barts Health NHS Trust, London, UK
  4. 4 Department of Medicine (DAME), University of Udine, Udine, Friuli-Venezia Giulia, Italy
  5. 5 Department of Emergency Medicine, Ospedale Civile di Latisana, Latisana, Friuli-Venezia Giulia, Italy
  6. 6 Department of Radiology, Ospedale Civile di Latisana, Latisana, Friuli-Venezia Giulia, Italy
  1. Correspondence to Dr Daniele Orso, Department of Medicine, University of Udine, Udine, Friuli-Venezia Giulia, Italy;{at}


Purpose Early diagnosis of COVID-19 has a crucial role in confining the spread among the population. Lung ultrasound (LUS) was included in the diagnostic pathway for its high sensitivity, low costs, non-invasiveness and safety. We aimed to test the sensitivity of LUS to rule out COVID-19 pneumonia (COVIDp) in a population of patients with suggestive symptoms.

Methods Multicentre prospective observational study in three EDs in Northeastern Italy during the first COVID-19 outbreak. A convenience sample of 235 patients admitted to the ED for symptoms suggestive COVIDp (fever, cough or shortness of breath) from 17 March 2020 to 26 April 2020 was enrolled. All patients underwent a sequential assessment involving: clinical examination, LUS, CXR and arterial blood gas. The index test under investigation was a standardised protocol of LUS compared with a pragmatic composite reference standard constituted by: clinical gestalt, real-time PCR test, radiological and blood gas results. Of the 235 enrolled patients, 90 were diagnosed with COVIDp according to the reference standard.

Results Among the patients with suspected COVIDp, the prevalence of SARS-CoV-2 was 38.3%. The sensitivity of LUS for diagnosing COVIDp was 85.6% (95% CI 76.6% to 92.1%); the specificity was 91.7% (95% CI 86.0% to 95.7%). The positive predictive value and the negative predictive value were 86.5% (95%CI 78.8% to 91.7%) and 91.1% (95% CI 86.1% to 94.4%) respectively. The diagnostic accuracy of LUS for COVIDp was 89.4% (95% CI 84.7% to 93.0%). The positive likelihood ratio was 10.3 (95% CI 6.0 to 17.9), and the negative likelihood ratio was 0.16 (95% CI 0.1 to 0.3).

Conclusion In a population with high SARS-CoV-2 prevalence, LUS has a high sensitivity (and negative predictive value) enough to rule out COVIDp in patients with suggestive symptoms. The role of LUS in diagnosing patients with COVIDp is perhaps even more promising. Nevertheless, further research with adequately powered studies is needed.

Trial registration number NCT04370275.

  • COVID-19
  • ultrasonography
  • diagnosis
  • emergency department

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Handling editor Simon Carley

  • Twitter @Orso_dan

  • Contributors CCDG designed the study, collected the data, wrote the first draft and supervised the final draft, he is responsible for the overall content as the guarantor; NA designed the study and collected the data, wrote the first draft and supervised the final draft; GX collected the data; MB reviewed the first draft and wrote the final draft; UGS collected the data; MT collected the data; DO reviewed the lung ultrasound images, performed the statistical analysis, wrote the first draft and supervised the final draft; FC reviewed the CXR images and the final diagnosis; GA reviewed the final diagnosis; SM reviewed the CXR images; RC designed the study, reviewed the lung ultrasound images and supervised the final draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.