Abstract
The massive raise of COVID-19 cases all over the world is leading to
unprecedented pressures on healthcare services.
Growing evidence is highlighting that COVID-19 is a systemic condition
that requires doctors with multiple expertise. Paediatricians are
trained in these skills. Considering the issue of staff shortage that is
facing every country in the world, and the complexity of COVID-19,
paediatricians may represent an important source of ready and skilled
specialists that can quickly translate the paediatric practice in the
COVID-19 care.
We report our experience of paediatricians engaged in the fight against
COVID-19 within adult COVID-19 wards. In particular, we focus on the
importance of a skill of some paediatricians in their clinical practice,
namely the use of lung ultrasound which has also become fundamental in
the management of adult patients with COVID-19, especially for some
categories such as pregnant women.
Since the beginning of the SARS-CoV-2 spread outside China, as well as
several hospitals have changed their organization in order to increase
critical care capacity and isolation areas to COVID-patients, and to
generate new flows to guarantee safety and care also to non-COVID
patients, also pediatric practice has changed completely.
SARS-CoV-2 is rarely involving children, and most of the time pediatric
COVID-19 disease is mild.1Moreover, parents stopped to
routinely bring their children to the hospital either because of fear in
contracting the infection or due to a lockdown-related drop of seasonal
infectious diseases.2
As a consequence, the workload of pediatricians has significantly
reduced in these months3 and therefore their inclusion
in COVID-19 units should be considered by Institutions.
Although not directly involved in adult care, pediatricians may play a
significant role in managing COVID-19-like patients for several reasons.
From a clinical point of view, several common clinical scenarios can be
included in COVID-19 adults that overlap with common pediatric
conditions for which pediatricians, especially some categories of them,
are already accustomed to their diagnosis and management (Table
1).4.5
In the last years, in several pediatric settings, lung ultrasound (LUS)
has become the first-line imaging method in children evaluated for
respiratory disease, allowing the real time diagnosis and monitoring of
lung involvement.6-13
In recent years, several studies have shown that LUS is a useful and
accurate tool for detecting pneumonia in children and it may be better
than chest radiography in the diagnosis of community-acquired
pneumonia.6-9,13 Studies are showing that LUS is able
to predict more severe pneumonia, monitor antibiotic response and,
recently, different LUS patterns have been able to differentiate viral
from bacterial pneumonia by defining their
etiology.6,9,13
Many studies have described and validated LUS scores (based mainly on
vertical artifacts and subpleural consolidations) in neonatal
respiratory disorders10and
bronchiolitis.11,12
For the development of lung ultrasound studies on the pediatric
population but also for the development of the use of LUS in pediatric
clinical practice, over the years it has been fundamental not only the
references to studies performed on adults14,15and
therefore the translation in the clinical prediatric practice of
knowledge acquired from these studies; but a true collaboration between
pediatric specialists and specialists of the adult population was also
fundamental, especially for the interpretation of some ultrasound
findings such as in the case of vertical artifacts and ultrasound
interstitial syndrome.7,14,15
Since the outbreak of the pandemic, this sharing/collaboration of
experiences and studies has assumed an ever greater force that takes
shape every day in daily clinical practice in the fight against
COVID-19.
In particular, it is not a coincidence that a pediatrician was the one
who suggested to the medical community to use ultrasound more frequently
in suspected COVID-19 patients and also the one who described the first
case also the one who described the first case of COVID-19 (an adult
patient) diagnosed and managed with thoracic
ultrasound.16-18
Since then, LUS has played a key role in the management of patients with
COVID-19 pneumonia.
Importantly, the ultrasound patterns of viral pneumonia and
bronchiolitis in children are similar to those seen in COVID-19
pneumonia, such as pleural line irregularities and vertical artifacts
(B-lines) with patchy distribution, sub pleural consolidations and white
lung areas, making easier for pediatrician to detect pathological LUS
patterns in adults with COVID-19 (Figure 1).
Furthermore in general, the basic LUS semeiotics of COVID-19 pneumonia
does not differs in adults and children.19-21
In order to allow comparing the severity of COVID-19 pneumonia of
different patients, limiting the subjectivity and the
operator-dependence of the exam, the standardization of the ultrasound
semiotics of COVID-19 pneumonia and the LUS score of severity of
COVID-19 pneumonia have been proposed, and in the drafting of which a
pediatrician (D.B.) actively participated.19-20
Although they could face several limits dealing with adult patients, the
habit to manage complex patients with multi-systemic diseases and
poli-pharmacological therapies gives to pediatricians an important
source of strength to contribute to the management of adult COVID-19
patients.
Probably all these strengths could also reduce the anxiety, stress and
feeling of uncertainty that doctors who find themselves working in a
different field from which they were trained can feel.
On the other hand, the major barrier could be represented by
medico-legal concerns, as common co-morbidities and complications of
adult patients are far from the pediatric daily practice. A safe and
effective strategy for COVID wards could be once again a
multidisciplinary team. A close collaboration between pediatricians and
internists (even mixing more and less experienced doctors) could be
precious to re-introduce the former to adult patients and to ensure
mutual clinical support.
Given their skills in pediatric infectious diseases and lung ultrasound,
pediatricians D.B. and L.P. have been included in the management of
adults with COVID-19 in their Institutions as well as many other
colleagues in Italy.
In Bologna two internists, two pediatricians (including L.P.), one
endocrinologist and a group of mixed pediatric and internist residents
managed a COVID ward, for 5 weeks from March 16, 2020 to April 17, 2020.
It was a 30-bed ward, with 2 negative pressure room for patients on
CPAP. In those 5 weeks, a total of 145 patients were managed on oxygen
therapy and CPAP. As well, other three pediatricians have been
integrated in other three COVID equips. Many specialists were involved
in COVID wards, but pediatricians were the only who supported actively
the internists in the management of patients. The success of this
collaboration derived from a common way of thinking in dealing with
patients and multisystemic diseases. Even if pediatrician are not
confident with adults’ common pathologies, the habits to look at the
patient as a whole helped to early recognize worsening signs and to
facilitate the discussion about patients.
These equal views helped to reduce stress in a highly stressful
situation, which could have been worse in a context where internists
would have had to carry the whole work on their shoulders, while other
specialists would have felt frustrated to manage situations that were
risky and not congenial to them.
In Rome, a pediatrician (D.B.) became responsible for LUS evaluation of
pregnant women with respiratory conditions, in order to reduce the
routine use of chest X-rays and computed tomography scans in this
specific group, reserving these tools to selected
cases.22,23
In particular, from March 2020 to date, 62 pregnant women positive for
COVID19 , have been evaluated by chest ultrasound. No positive pregnant
woman has undergone a chest CT scan so far and LUS has become the first
level tool for all to diagnose pneumonia.
The past, current and projected scale of distress among healthcare
professionals, while understandable, has been and is of grave
concern.9 The short- and long-term negative effects of
this disease have the potential to have both physical and psychological
consequences impacting significantly on the quality of life of both of
the health worker and their family. The existing risks to the well-being
of healthcare professionals are compounded under the current highly
pressurized conditions.24
Concomitantly, the whole world is facing a severe shortage of Personal
Protective Equipment3, which contributes to the high
number of infections, disease and deaths among healthcare workers
worldwide. Altogether, these factors determine an increasing shortage of
doctors worldwide, including the richest countries.
Having adequate numbers of health workers and obtaining the
collaboration among different specialists for whom less uncomfortable
conditions possible are desired, will be critical to winning the battle
against COVID-19.
Growing evidence is highlighting that COVID-19 is a systemic condition
that requires doctors with multiple expertise25:
general support measures, experience in managing antivirals, antibiotics
and biological agents, respiratory support, imaging interpretation and
experience in point-of -care ultrasound.
Considering the issue of staff shortage that is facing every country in
the world, the complexity of COVID-19, the rare and mild involvement of
SARS-CoV-2 in children1 and the reduced access to
pediatric health facilities2, the pediatricians may
represent an important source of ready and skilled specialists that can
quickly translate the pediatric practice in the COVID-19 care.