text: Along the same lines, echocardiographic studies performed on patients with suspected or confirmed COVID-19 should be as focused as necessary to obtain diagnostic views but should also be comprehensive enough to avoid the need to return for additional images. Each study should be tailored to the indication and planned in advance, after review of images from past exams and other imaging modalities. Complete exams may be necessary in some circumstances. Plans for ultrasound enhancing agent (UEA) utilization should be made in advance in order to prevent a sonographer having to wait for the agent to be delivered or having to use more personal protective equipment to exit the patient's room to obtain the agent. While the safety of UEAs specifically in COVID-19 cases has not yet been determined, they have been used and proved safe in ICU patients. The use of UEAs may therefore be considered in such cases as long as the benefits in terms of diagnostic yield and scan time are favorable.
  Finally, the results of the exam should be rapidly reviewed and key findings recorded immediately on the patient's record and communicated to the primary care team to allow hemodynamic management to be optimized.
  Imaging team should ensure rapid review and reporting of key findings in the patient's record and communicating them with the primary care team.
  Airborne precautions add special masks (e.g. N-95 or N-99 respirator masks, or powered air purifying respirator – PAPR systems), and shoe covers.
  The local application of each component of PPE can vary according to level or type of risk for TTEs and stress echo exams, but airborne precautions are required during a TEE for suspected and confirmed cases, due to the increased risk for aerosolization. A surgical face mask for patients is recommended for those who are symptomatic, undergoing surface echo examination provided institutional resources allow this strategy for source control.10
  It is important to reiterate that the type of PPE to be used on specific cases will depend on local institutional policy and resources. The US Centers for Disease Control (CDC) provides updated guidelines for PPE use for healthcare workers.4
  Equipment care is critical in the prevention of transmission. Some institutions cover probes and machine consoles with disposable plastic and forego the use of ECG stickers. It is important to note that the benefit of using protective covers must be balanced against the risk of potential for suboptimal images and prolongation of scan time. Some institutions set aside certain machines or probes for use on patients with suspected or confirmed infection. Although SARS-CoV-2 is sensitive to most standard viricidal disinfectant solutions, care must be taken when cleaning. Local standards vary, but echocardiogram machines and probes should be thoroughly cleaned, ideally in the patient's room and again in the hallway. Smaller, laptop-sized portable machines are more easily cleaned, but use of these machines should be balanced against potential tradeoffs in image quality and functionality. Please consult vendors' disinfecting guidelines available on their websites, as procedures vary and could affect the functionality of machines. TEE probes should undergo cleaning in the room (including the handle and chord), then be transferred in a closed container to be immediately disinfected according to the manufacturer's recommendations. The exact steps to be followed for disinfection of the TEE probe and equipment will depend on local institutional protocols that usually are guided by infectious disease experts and resource availability. The American Institute for Ultrasound in Medicine (AIUM) has specific guidelines for disinfection of ultrasound equipment.11