ASE Statement on Point-of-Care Ultrasound (POCUS)
During the 2019 Novel Coronavirus Pandemic© 2020 American Society of Echocardiography

Amer M. Johri, MD, MSc, FRCPC, FASE (Chair), Benjamin Galen, MD, FACP, James N.
Kirkpatrick, MD, FASE, Michael Lanspa, MD, FASE, FCCM, Sharon Mulvagh, MD, FASE,
FRCPC, Ritu Thamman, MD, FASE, Kingston, Ontario, Canada; Bronx, New York; Seattle,
Washington; Salt Lake City, Utah; Halifax, Nova Scotia, Canada; Pittsburgh, Pennsylvania
From Queen’s University, Kingston, Ontario, Canada (A.M.J.); Albert Einstein College ofMedicine and Montefiore Medical Center, Bronx, New York (B.G.); University of Washington
Medical Center, Seattle, Washington (J.N.K.); Intermountain Medical Center and the Universityof Utah, Salt Lake City, Utah (M.L.); Dalhousie University, Halifax, Nova Scotia, Canada (S.M.);
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (R.T.).
The following authors reported no actual or potential conflicts of interest in relation to thisdocument: Amer M. Johri, MD, MSc, FRCPC, FASE, Benjamin Galen, MD, FACP, James N.
Kirkpatrick, MD, FASE, Michael Lanspa, MD, FASE, FCCM, Ritu Thamman, MD, FASE. The
following authors reported relationships with one or more commercial interests: Sharon
Mulvagh, MD, FASE, FRCPC, is a consultant for Lantheus Medical Imaging and serves on thesteering committee/SOUL trial for NovoNordisk.

1©American Society of Echocardiography

ASEcho.org

Notice and Disclaimer: This statement reflects recommendations based on expert opinion,
national guidelines, and available evidence. Our knowledge with regard to coronavirus disease(COVID-19) continues to evolve, as do our institutional protocols for dealing with invasive andnon-invasive procedures and practice of personal protective equipment (PPE). Readers are
urged to follow national guidelines and their institutional recommendations regarding bestpractices to protect their patients and themselves. These reports are made available by theAmerican Society of Echocardiography (ASE) as a courtesy reference source for its members.
The reports contain recommendations only and should not be used as the sole basis to makemedical practice decisions or for disciplinary action against any employee. The statements andrecommendations contained in these reports are primarily based on the opinions of experts,
rather than on scientifically-verified data. ASE makes no express or implied warranties
regarding the completeness or accuracy of the information in these reports, including thewarranty of merchantability or fitness for a particular purpose. In no event shall ASE be liable toyou, your patients, or any other third parties for any decision made or action taken by you orsuch other parties in reliance on this information. Nor does your use of this information
constitute the offering of medical advice by ASE or create any physician-patient relationshipbetween ASE and your patients or anyone else.

2©American Society of Echocardiography

ASEcho.org

Why Conduct POCUS in COVID-19 Infection?
Although lung injury is common in COVID-19 infection, myocardial injury may be present
in more than a quarter of patients with critical disease.1 Thus the rapid, bedside assessment of
the heart, chest, and vessels by point-of-care ultrasound (POCUS) has propelled this tool to
the frontlines of the fight against the COVID-19 pandemic. POCUS is usually conducted by thetreating provider to obtain real-time information for management decisions. Cardiac views are
frequently obtained along with non-cardiac views such as the chest (lung, pleura) and vessels(neck and leg veins, aorta). In infection with severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) in particular, POCUS may help triage the dyspneic patient and determine needfor subsequent imaging (echocardiogram, echo; computerized tomography, CT; etc). A modified
version of the ASE POCUS protocol may be of value in suspected or confirmed COVID-19
infection (Figure 1). The base ASE POCUS protocol can be accessed free online at:https://aseuniversity.org/ase/lessons/47.2

Figure 1. ASE POCUS Protocol Imaging Views in Suspected or Confirmed COVID-19 Infection. The ASE modified
POCUS protocol includes, basic cardiac views, subcostal views for IVC and pericardial fluid, and chest views. This
protocol may assist in the initial cardiopulmonary assessment of patients with COVID-19 infection if POCUS isdeemed indicated. IVC, inferior vena cava.

Cardiac POCUS: A well-illustrated case series of the application of focused ultrasoundin patients with severe COVID-19 infection and associated cardiovascular (CV) disease from
Wuhan was recently presented.3 Table 1 lists cardiac POCUS findings and indications. Earlyreports suggest that cardiac POCUS indications in COVID-19 include:
1. Detection or characterization of pre-existing CV disease.
2. Early identification of worsening cardiac function, either due to known pre-existing
disease or associated with the infection.
3. Monitoring and examination: POCUS may be able to assess changes in cardiac function
over time through quick routine examinations, perhaps in lieu of heart and lung auscultation,
which can be challenging in critical care settings due to pronation, ambient noise, and PPE.
4. Elucidation of CV abnormalities potentially associated with COVID-19:
a. Early reports suggest that some patients develop pericardial effusion and/or
myocarditis that can progress to shock.4
3©American Society of Echocardiography

ASEcho.org

b. A hypercoagulable state may be associated, leading to deep venous thrombosis(DVT) and pulmonary embolism with associated right ventricular findings andacute pulmonary hypertension
c. LV systolic dysfunction, either global or regional, may be associated withmyocarditis, stress-induced cardiomyopathy pattern, or epicardial or microvascularcoronary thrombosis.
Lung Pocus: Whenradiographic studies such as CT
scan might be limited, lung POCUS
can be used to trend severity of
COVID-19 pneumonia as an adjunctto oximetry and physicalexamination. Lung and vascular
POCUS applications in COVID-19
are listed in Table 1. Characteristiclung findings in preliminary
publications are consistent with aviral pneumonia: a thickened andirregular pleural line, and scattered
B-lines (mild disease). In severe
disease, this can progress toconfluent B-lines with pulmonary
consolidation, including air
bronchograms. POCUS is useful to
exclude other chest pathologies incritically ill patients, such as
pneumothorax (particularly inpatients on positive pressure
ventilation) and symptomatic large
pleural effusion.
Vascular POCUS for procedural
guidance and access is wellestablished in acute settings.
Assessment of the inferior vena
cava (IVC) and/or jugular venous
pulsation (JVP) plays an importantrole in hemodynamic assessment ofcritically ill patients to enhance thephysical exam and in theassessment of fluid status. Deepvein thrombosis risk increases withany critically ill bed-bound patient; moreover, early reports indicate an association between
COVID-19 and a prothrombotic state. A unilateral DVT study performed by a sonographer is
4©American Society of Echocardiography

ASEcho.org

relatively quick and focused. However in the case that a sonographer is not available, and incontext of the pandemic, the 2-point compression POCUS technique may be considered bypractitioners trained in the technique.5
When to Perform POCUS in COVID-19?
Not all patients with COVID-19 infection
require a POCUS examination. However, if
cardiac and chest ultrasound is indicated,some institutions may choose POCUS as
the first-line application of ultrasound.
Deterioration in clinical status may thentrigger a more extensive exam such as alimited transthoracic echocardiography(TTE) guided by the POCUS images. The
primary advantage of using POCUS first in
COVID-19 is reduction of exposure to otherpersonnel and locations, permitting
conservation of PPE. Disadvantages include
potentially poorer imaging resolution
compared with systems used forcomprehensive TTE, missed findings,
operator inexperience, archiving issues, andinability to immediately convert the POCUS
to a comprehensive examination if needed.
A workflow algorithm for patients with
COVID-19 infection in whom further
cardiopulmonary ultrasound is indicated isprovided in Figure 2. If POCUS examination
is available, and the scan sufficiently
answers the clinical question, then the needfor subsequent TTE may be obviated. If the
POCUS scan is insufficient, or reveals
Figure 2. POCUS Workflow in Suspected or Confirmed COVIDfindings requiring comprehensive evaluation,
19 Infection. Potential workflow for POCUS during the COVID-19
then TTE may be considered as appropriate.
pandemic, in the instance that cardiopulmonary ultrasound is
Limited TTE can be planned and guided byindicated. If available, and there is suspicion of cardiopulmonary
the POCUS findings to minimize sonographer
abnormality requiring further evaluation, POCUS can be the firstline ultrasound performed. If the POCUS performed by a trained
exposure. In some instances, POCUS may be
operator is sufficient to either exclude or define theinsufficient to exclude a suspected cardiac
cardiopulmonary abnormality, then further TTE may not beabnormality, for example in the case of difficult
required. If the POCUS was insufficient then limited or
image acquisition, and it may be more efficientcomprehensive TTE may be considered as appropriate. PPE,
personal protective equipment; TTE transthoracic
for a skilled sonographer to rapidly scan theechocardiography.
patient, rather than have a POCUS operator
struggle with prolonged attempts. Judicious
use of ultrasound must be considered to avoid
unnecessary exposure of personnel to contagion and conserve the use of limited resources
5©American Society of Echocardiography

ASEcho.org

such as PPE. Caution must be exercised to ensure that the suggested POCUS workflow
algorithm is not increasing utilization of unnecessary or inappropriate TTE.
How to Perform POCUS in COVID-19 infection
Safety and cleaning: PPE implementation for sonographers, and machine cleaning
principles are described in the parent document to this supplement and apply to POCUS.
Because of the size and flexibility of POCUS devices, institutions may decide to dedicate thesedevices to a fixed location, such as an isolated COVID-19 unit, with meticulous cleaning
between patient exams and at the end of each day in a dedicated cleaning storage facility within
the unit. The suggestions for scanning and cleaning are summarized in Table 2 (modified fromthe American College of Emergency Physicians (ACEP))6. This is a suggested checklist;
however specific steps, procedures, and their order may vary depending upon institutional
guidance, the care environment, and management pathway. It is important to recognize that
institutions may develop their own protocols for decontamination; and that these should be
posted clearly. Additional information on transducer cleaning can be found on the American
Institute of Ultrasound in Medicine (AIUM) website.8
Table 2. Example POCUS Device Cleaning Checklist in Suspected or Confirmed
COVID-19 Infection.
Review PPE Precautions
Plan scans to minimize time and risk
Remove excess items from machine before entering room
1
Mask patient (institution-specific)
2

After scan: inspect and wipe probe/device wearing PPE

3

Initial clean in patient’s room

4

Push machine out of room while doffing gown
Sanitize hands, new gloves, keep mask and face shield on
Re-inspect machine and perform low level disinfection cleaning withappropriate agent using product recommended
wet time (usually 2 min), allow dry time
Remove other PPE
Remove gloves, sanitize hands again
Record personnel, document scan

5

Other Considerations
6

Consider using aliquot or single use gel packets

7

Consider probe/device covers (institution-specific)

8

Consider dedicating machine to unit (institution-specific)

9

Hold in-service for users, share knowledge

10

Periodically review institutional and society guidance

PPE, personal protective equipment.

6©American Society of Echocardiography

ASEcho.org

Archiving and storage: Given the potential for deterioration in patients with COVID-19
infection, every attempt should be made to store, archive and document POCUS results to allow
for image comparison. This helps to reduce the need for repeat scans that would impinge uponscarce PPE resources, and the risk of exposure. At the very least, results should be
documented in the physical exam or investigations section of the patient’s chart.
Who Should Perform POCUS?
All POCUS practitioners should operate within their skillset as described by the ASE
Recommendations for Echo Labs Participating in POCUS and Critical Care Echocardiography
Training.9 Some users may have POCUS credentials from societies such as the American
College of Chest Physicians and/or the Society for Hospital Medicine. Many institutions haveplanned for the possibility of a tiered response to the crisis, as proposed by the Society of
Critical Care Medicine.10 In such a response, non-intensivist physicians might be directly
managing patients with COVID-19. Novice practitioners may be recruited to use POCUS in the
midst of a surge of patients. These individuals should receive proper training, but the usual
modes of teaching by practicing on patients are currently inadvisable. Simulators are an
approach to introduce POCUS image acquisition and interpretation. Several on-line modules
are available that offer an ability to learn background knowledge, such as the ASE modules2
and introductory lung modules available at PocusJournal.com.11 To enhance training andenable access to experts, commercially available platforms now exist that utilize interactive
teleconsultative tools for remote guidance and supervision.
Summary
In the case that cardiopulmonary ultrasound is indicated in a patient with COVID-19
infection, POCUS may be considered the first-line ultrasound examination performed, whichthen guides the need for further imaging. This approach may help to conserve personnel and
PPE, as well as limit exposure to other personnel and locations. Given the potential for rapid
clinical deterioration in patients with COVID-19 infection, every attempt should be made to storeand document POCUS results to reduce the need for repeat examination. Meticulous cleaningof any POCUS device is critical to reduce the risk of SARS-CoV-2. POCUS must be performed
by individuals with the correct skill set, an understanding of the limitations of this technology,
and meticulous attention to PPE and machine cleaning.

7©American Society of Echocardiography

ASEcho.org

References
1. Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. Coronavirus Disease 2019
(COVID-19) and Cardiovascular Disease. Circulation. 2020.
doi.org/10.1161/CIRCULATIONAHA.120.046941.
2. Cardiovascular Point-of-Care Imaging for the Medical Student and Novice User. American Society of
Echocardiography. https://aseuniversity.org/ase/lessons/47. Accessed: Mar 25, 2020.
3. Zhang L, Wang B, Zhou J, Kirkpatrick J, Xie M, Johri AM. Bedside Cardiac Ultrasound in COVID-19
Infection From the Wuhan Epicenter: Role of Cardiac Point of Care Ultrasound (POCUS), Limited
Transthoracic Echocardiography, and Critical Care Echocardiography. J Am Soc Echocardiogr. 2020;
DOI: 10.1016/j.echo.2020.04.004.
4. Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Bondi-Zoccai G, et al. Cardiovascular
Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease2019 (COVID-19) Pandemic. J Am Coll Cardiol. 2020. doi.org/10.1016/j.jacc.2020.03.031.
5. Lee JH, Lee SH, Yun SJ. Comparison of 2-point and 3-point point-of-care ultrasound techniques fordeep vein thrombosis at the emergency department: A meta-analysis. Medicine (Baltimore).
2019;98:e15791. doi.org/10.1097/MD.0000000000015791.
6. Ultrasound Machine Cleaning Process for COVID-19. American College of Emergency Physicians.
www.acep.org/globalassets/images/acep-us-machine-cleaning-covid-19.pdf. Accessed: Mar 25, 2020.
7. List N: Disinfectants for Use Against SARS-CoV-2. United States Environmental Protection Agency.
www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Accessed: Mar 25, 2020.
8. Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers andEquipment Between Patients as well as Safe Handling and Use of Ultrasound Coupling Gel. American
Institute of Ultrasound in Medicine. www.aium.org/officialStatements/57. Accessed: Mar 25, 2020.
9. Kirkpatrick JN, Grimm R, Johri AM, Kimura BJ, Kort S, Labovitz AJ, et al. Recommendations for
Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) andCritical Care Echocardiography Training: Report from the American Society of Echocardiography. J Am
Soc Echocardiogr. 2020;33:409-22.e4. doi.org/10.1016/j.echo.2020.01.008.
10. United States Resource Availability for COVID-19. Society of Critical Care Medicine.
sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19?_zs=jxpjd1&_zl=w9pb6.
Accessed: Mar 14, 2020.
11. Wu L, Nihal S, Montague S, Johri A. Introduction to Lung POCUS. POCUS Journal.
http://pocusjournal.com/education/introduction-to-lung-pocus. Accessed: Apr 3, 2020.

8©American Society of Echocardiography

ASEcho.org