Echo in the COVID-19 era: Planning for the new normal

Our first webinar took place on Wednesday 13 May 2020 and was organised jointly with the Cardiology Section of the Royal Society of Medicine.

The COVID-19 pandemic created an unprecedented challenge for the health service. The service delivery of echocardiography had to be adjusted in both inpatient and outpatient settings. This webinar updated the audience on the main adaptations made pre and during COVID-19 and discussed suggestions of optimising delivery of echocardiography post the acute phase of the pandemic. We hope this information will be of value now and in the future should there be another outbreak.


All answers to questions are the opinion of the individual speaker, not the British Society of Echocardiography.

Q: Nurses providing full intimate care of sick patients are just as close as sonographers and for far longer changing dirty sheets and cleaning away infectious body fluids. If you say you need FFP3 against PHE guidance, you are saying that your staff deserve to be treated differently from nurses. In an ideal world we would all wear full PPE but there is not enough supplied – hospitals only get what PHE guidance suggests they need, and nurses treated COVID +ve patients do not get FFP3.

A: We should all have appropriate PPE. I would refer all to this review article. - Dr Bushra Rana

Q: Our trust does not believe we should be in full PPE for TTE even on confirmed cases. Luckily, our consultants are behind us and have said we have to wear full PPE. We have been taking our own to the wards but still getting challenged. However, on our green patients we have only been wearing plastic aprons, gloves, and surgical masks – long sleeve gowns sound very sensible but feel we will not be able to get this PPE from the hospital store.

A: We have done similar until recently with plastic aprons, and in the cold sites/OP echos we are doing this. However, the evidence (albeit limited and extrapolated) suggests there is potential exposure to the upper body during close contact. We have raised our own funds and sourced our own PPE. None of this is ideal, but as you have demonstrated sticking together as a team is key. - Dr Bushra Rana

Q: Is anyone thinking of resuming DSE? And if so, what time margin for consent is being utilised?

A: We are firstly ensuring that the triaging process for DSE is quite rigorous. Those who are urgent will be prioritised. - Ms Kelly Victor

A: Some Trusts are planning for the return of stress echo over the next few weeks. I think dobutamine will be preferred initially to exercise due to lower risk of aerosol generation. We plan to start with 90 minute slots. - Dr Dan Augustine

Q: FFP3 masks are not as per Public Health England pathway. Do other sites have issues, or should BSE provide further evidence to PHE to endorse this?

A: The arguments are focused on what is aerosol generating and what is not. PPE guidance risk stratifies based on a particular clinical activity at a specific location or proximity to a patient and their aerosol generating ability. The difficulty is the reality and limited studies suggest many more procedures/activities appear to be AGP (including clinical examination/IV cannulation) and we are likely to be greatly underestimating the risk. What is stark is the lack of ICU staff deaths in the UK where appropriate PPE is worn. Many societies have raised concerns about PHE approach to PPE. We need more data but personally I would argue while real doubt and limited evidence highlights to the contrary to current UK guidance, more precautionary approach is ethically justified. - Dr Bushra Rana

Q: Once service or part services resumes, how often should sonographers be tested for COVID?

A: At present we are only being tested if we have symptoms or if someone in our household has symptoms. The frequency with which we are tested will probably depend on the incidence of COVID in our hospital, the areas in which we are working (hot vs cold sites), and the individual Trust guidance. - Ms Kelly Victor

Q: Following NHS guidance, we are only offered full PPE for ITU patients only. Not what you have stated for all COVID +ve patients

A: We have agreed our PPE levels as a cardiology team. Where we have deviated from the PHE guidance, we have sourced our own funding and PPE. - Dr Bushra Rana

Q: Does BSE have any advice for sonographer training as outpatient appointments restart during the COVID period?

A: There may be some capacity for trainees to perform Level 1 scans under supervision and have this reviewed by a senior physiologist. This would mean that still only one operator would come into contact with the patient (limiting spread) and only one lot of PPE is used. - Ms Kelly Victor

A: This really is very difficult and will continue to prove challenging. We have stopped non-essential patient contact which clearly stops a hands on training programme in Echo. Trainees can continue to learn and develop analysis and reporting skills off-line and the first step in re-starting hands on learning could be to start with pairing up to scan the tested COVID negative inpatients. The BSE Education Committee are I believe working on some excellent on-line training material which will be of undoubted support. - Mr Michael Purdon

Q: Do you see Level 1 scanning being used more to triage the need for a full TTE in an attempt to reduce the burden on the echo departments?

A: We have taken this approach to the inpatient service, unless the question is around issues that require more detailed answers like valve pathology. However, the aim has been to limit exposure/scan time in the first instance especially if we have no imaging previously on the patient. From here we then decode if further detailed scanning is needed. We are finding good proportion are sufficient on hand held devices. - Dr Bushra Rana

Q: Should more departments be starting physiologist/scientist-led valve surveillance clinics to support these patients and reduce cardiologist clinic time?

A: Yes, I think now is the time for departments to engage more with scientist led services. - Dr Dan Augustine

Q: With echo, do you recommend Lung US as well, and vice versa?

A: I think it can answer many questions that you need at the bedside – especially in intensive care. - Dr Segun Olusanya

Q: If a patient is on Warfarin, will they be protected from hyper coagulation as complication of COVID?

A: I do not think there is enough data on this. I do not think it completely protects as we have seen people fully anticoagulated on heparin still develop clots. However, it should reduce the risk in theory – something to study. - Dr Segun Olusanya

Q: Once activity resumes to ‘normal’, what time slots for TTE would you advise?

A: We are looking at 1-hour slots with 15 minutes turn around time for cleaning and reporting (duration of scan will obviously depends on complexity of pathology), but we are factoring in social distancing measures and limited patients in waiting areas. Therefore, this will partly depend on your setup and ability to comply with these measures also. We are managing 5-6 slots over a day. - Dr Bushra Rana

Q: Why are sealed goggles not required for AGP’s when aerosol can be absorbed by the eyes? Are goggles/visors adequate?

A: Very sensible question. I am afraid I have no special knowledge regarding efficacy of different styles of eye protection. I would imagine that unsealed eye protection would be reasonable at preventing direct splashes. I am afraid I do not have a sense of the threat caused to healthcare workers of transmission via the conjuctival mucosa following AGPs. What I would say is that in the different environments I have worked in within my trust we have never been provided with sealed eye protection, and this includes for intubation. - Dr Bushra Rana

Q: Are COVID patients more likely to contract vegetations on valves?

A: I don't think we know 100% is this is the case, but based on empirical evidence and discussions with colleagues, I don't think we are seeing an increased incidence of vegetations in COVID. We know that a potential source is central lines so perhaps there is a small increased risk, but it isn't currently clear there is an increased risk due to COVID. - Dr Segun Olusanya

Q: We have a GE handheld scanner in our trusts however, can you advise how to archive the images from these machines please?

A: As Michael Purdon stated they connect current gen VScans via Wi-Fi to their system (assume dicom PACS).  1st gen VScan’s did not offer dicom connection.  Please contact your regional GE team for 1:1 assistance. You may also find this flyer useful.  - GE Healthcare representative

A: Have you discussed with your IT and clinical engineering teams? They usually sort this. We are very fortunate as we have our own in-hospital medical expert (Dr Matt Shun-Shin) who has set this up across the Trust sites with IT. The other option is to involve the company as they often can advise. - Dr Bushra Rana

Q: What is in place for our echo techs who are vulnerable, e.g. have chronic illnesses, comorbidities that are high risk to COVID? What advice is there for them?

A: This will need to be done in line with changes to government restrictions. We have published guidance on our website and include conditions that have been identified as ‘higher risk’. Triage is very important to weigh up benefit and timing of echo. - Dr Dan Augustine

Q: We have 2 Vscanners for inpatients that we use. One is for COVID negative patients and one is for COVID positive patients. Which scanner should you use for suspicious patients in the amber zone?

A: From the previous Imperial COVID webinar it was observed that hand held echo devices are quick and easy to clean - following the guidance on approved agents by Vscan model owned should be done as detailed here. - GE Healthcare representative

A: We should use the dirty one – which is cleaned with tristel wipes. - Dr Bushra Rana

Q: How are people cleaning the Philips Lumify handheld, including the Samsung tablet? For Cat ½ and Cat 3.

A: There is some guidance here. Tablets should be easier to clean using an alcohol based agent (the green Clinelle wipes work well). - Dr Segun Olusanya

Q: If checking the temperature of patients attending OP what cut off value would you use?

A: 37.8°C - Mr Michael Purdon, Dr Dan Augustine and Mr Shaun Robinson

Q: Are we to remain on Level 1 scans for now?

A: Yes, we would recommend that whilst the pandemic is ongoing that we remain with Level 1 scans. - Dr Dan Augustine

Q: We have been following HH scanner/focus study technique for all red nd amber cases for some weeks with on and off shift rotations. Despite these controls Echo Cardiographers are beginning to report backache as a result of holding the scanner esp when multiple cases in one COVID +ve area. They are proposing to prefer to use portable trollied echo machines. Are other centres experiencing the same? Advice?

A: No-one in my Trust has complained of backache or RSI's yet! We are using a portable echo machine, stripped down and off its trolley (on a stainless steel medical trolley). This can be fully cleaned with tristel wipes or appropriate claning solution. If using mainly HH scanners, I would suggest reducing the number completed in a single session on a ward, even though this means an increased changeover of PPE. Also, rotating the staff more frequently if possible. - Mr Michael Purdon

Q: When echoing ITU patients in prone position, is there any recommendation from BSE?

A: Not from BSE – there are a couple of papers describing the technique - this is the latest one and this is the original one. - Dr Segun Olusanya

Q: I undertake community echo. I believe our service should be fully supported and should be able to continue with precautions in place. What are your feelings on this?

A: COVID has resulted in practice being minimised on all levels - community, primary, secondary and tertiary care. This is in order to protect staff and patients, and the general spread of disease. As services recommence, yes it is agreed that a number of precautions will need to be in place to ensure this level of safety for staff and patients continues. This may include PPE, pre visit questionnaires etc. However it may be sometime before our practice returns to what we used to consider 'normal'. - Ms Kelly Victor

Q: How does the finding of RV dysfunction in COVID +ve patients (for the various reasons eluded to in the presentations) on ITU change the management?

A: Quite a lot, depending on severity. If mild, we may do nothing. If moderate to severe, and related to pulmonary hypertension, we may use pulmonary vasodilators, reduce the PEEP try and remove fluid, and in extreme cases use ECMO. - Dr Segun Olusanya

Q: What is the relevance and importance of obtaining a PASP in COVID patients? Does this change the clinical management?

A: If PASP is really high we sometimes treat it as it may improve cardiovascular function and oxygenation. - Dr Segun Olusanya

Q: Are there any centres planning to do (or already performing) COVID swab for all patients attending outpatient advances ECHO e.g. TOE, DSE or Bike Stress? Any data?

A: Our Trust have agreed to support swab testing for elective TOE cases. We will push to have all forms of Stress Echo included. - Mr Michael Purdon

A: I don't think so for elective outpatients currently but this may change as the Government proposes to increase testing. - Dr Dan Augustine

Q: What is the strategy for TOE and bubble contrast echos in days to come?

A: We have released guidance in this area. - Dr Dan Augustine

Q: Is radial RV function assessed visually as a general rule?

A: Yes, visually as a general rule. - Ms Kelly Victor

Q: If a patient has been on a ventilator for multiple weeks and now off. What is the cardiovascular risk/risk of thrombus during recovery and post COVID?

A: I do not think we have clear data on this. It will probably depend on their baseline risk and current mobility. - Dr Segun Olusanya

Q: We have been performing all inpatient Echo’s at the bedside. Most staff scan right-handed. Obviously, bedside scans are hard work and staff are more likely to have back problems. So, we have advocated them going out in pairs. Anyone else adopted this practice? This also helps with cleaning/decontaminating the echo machine in between every patient (if not using a handheld).

A: Certainly working in pairs would reduce the physical burden but I would just be mindful not to unnecessarily used up two lots of PPE for every patient. Perhaps it would be better to divide the workload and then visit patients separately. - Ms Kelly Victor

Q: Has anyone seen more pericardial abnormalities when scanning? Not just small effusions but organised substrate around/adherent to the RV free wall.

A: There doesn't seem to be much in the literature about this at present. There are articles suggesting that there may be more of a haemorrhagic component - perhaps this is what you are seeing? - Ms Kelly Victor

Q: Given the lack of routine experience in lung ultrasound; should it be routine? Would chest x-ray be more reliable? There may be an increase in SBE due to increased invasive lines.

A: You are right – most people are more experienced in chest x-ray and introducing a new technique right now would reduce diagnostic accuracy. However, if you have someone (radiologist/intensivist) who is skilled in lung ultrasound locally and can support you – it is worth learning in my humble opinion. - Dr Segun Olusanya

Q: Michael, are you providing patients a FRSM? If so, are you removing it from them before they leave the facility?

A: Yes, we are providing an FRSM before the patient enters the clinical room and asking them to remove it into an appropriate waste disposal bin as they leave. - Mr Michael Purdon

Q: What about ETT for remote areas where CTCA not available?

A: ETT isn't part of NICE recommendations for the assessment of chest pain. - Dr Dan Augustine

Q: For future follow ups and electives, is one COVID swab deemed negative going to be sufficient given the fact that 30% of the positive patients could be false be negative? Or is there going to be a guidance regarding the use of PPE as a standard for all cohorts?

A: This will vary depending on your local guidelines. Antibody testing may change this... - Dr Segun Olusanya

Q: Could you clarify where the guidance for ventilation/room air changes came from please? Is this from your local infection control or is there national guidance?

A: Click here to view the ARTP document. Agreed locally with our Trusts Infection Control team. - Mr Michael Purdon

Q: How sensitive lung ultrasound is to diagnose COVID? EACVI webinar says it is a new diagnostic tool and takes practice to do it properly?

A: Sensitivity 90-97%, Specificity 25%. It is very close to CT. However, the changes you see with COVID are common to ANY viral pneumonia (Flu, Varicella etc). So, the history is really important. If you are acting in your role as a sonographer all you can say is “recommend further testing”. - Dr Segun Olusanya

Q: What is the recommended total time for a scan in this situation?

A: There are so many individual variables that can alter scan time for patients - experience level of the sonographer, clinical questions, body habitus, patient position, location. I am not sure it is possible to give an exact figure. My personal opinion is that a level 1 scan and report should be achievable within 20 mins. - Ms Kelly Victor

Q: What can we expect the interventricular septum motion in patients with mechanical ventilation?

A: The IVS position will be dependent on the relative pressures within the LV and RV at any given point in time (point in the cardiac cycle). Mechanical ventilation alone in otherwise healthy individuals with a normal heart and lungs does not usually bring about significantly different intra-cardiac pressures such that there is a reversal of the usual left to right position of the IVS. However in diseased lungs (acute or chronic) elevated right heart pressures can cause displacement of the septum from right to left. It is also important to appreciate that positive pressure ventilation (when all of the work of generating a pressure gradient between the patient's chest and the gas to be inspired is performed by the ventilator increasing the pressure of the inspired gas) will reverse the usual respiratory variation in trans-aortic and trans-pulmonary flow. In modern ICU medicine we try to have patients awake and spontaneously ventilating as much as possible, which often involves a mixed negative/positive pressure picture, with the patient generating some negative intra-thoracic pressure themselves and the ventilator generating some positive pressure, which makes interpreting heart/lung interactions in these patients challenging and frequently unreliable.  If scanning a ventilated patient ask the intensivist which mode of ventilation is being used and is it exclusively positive pressure, negative pressure or a mixture of both to aid interpreting the scan. - Dr Richard Fisher

Q: My big concern is the impact on training – any suggestions as to how we can continue to provide the echocardiographers of tomorrow?

A: This really is very difficult and will continue to prove challenging. We have stopped non-essential patient contact which clearly stops a hands on training programme in echo. Trainees can continue to learn and develop analysis and reporting skills off-line and the first step in re-starting hands on learning could be to start with pairing up to scan the tested COVID negative inpatients. The BSE Education Committee are I believe working on some excellent on-line training material which will be of undoubted support. - Mr Michael Purdon