Chest radiograph at admission predicts early intubation among inpatient COVID-19 patients

Abstract

Objective The 2019 Coronavirus (COVID-19) results in a wide range of clinical severity and there remains a need for prognostic tools which identify patients at risk of rapid deterioration and who require critical care. Chest radiography (CXR) is routinely obtained at admission of COVID-19 patients. However, little is known regarding correlates between CXR severity and time to intubation. We hypothesize that the degree of opacification on CXR at time of admission independently predicts need and time to intubation. Methods In this retrospective cohort study, we reviewed COVID-19 patients who were admitted to an urban medical center during March 2020 that had a CXR performed on the day of admission. CXRs were divided into 12 lung zones and were assessed by two blinded thoracic radiologists. A COVID-19 opacification rating score (CORS) was generated by assigning one point for each lung zone in which an opacity was observed. Underlying comorbidities were abstracted and assessed for association. Results One hundred forty patients were included in this study and 47 (34%) patients required intubation during the admission. Patients with CORS ≥ 6 demonstrated significantly higher rates of early intubation within 48 h of admission and during the hospital stay (ORs 24 h, 19.8, p < 0.001; 48 h, 28.1, p < 0.001; intubation during hospital stay, 6.1, p < 0.0001). There was no significant correlation between CORS ≥ 6 and age, sex, BMI, or any underlying cardiac or pulmonary comorbidities. Conclusions CORS ≥ 6 at the time of admission predicts need for intubation, with significant increases in intubation at 24 and 48 h, independent of comorbidities. Key Points • Chest radiography at the time of admission independently predicts time to intubation within 48 h and during the hospital stay in COVID-19 patients. • More opacities on chest radiography are associated with several fold increases in early mechanical ventilation among COVID-19 patients. • Chest radiography is useful in identifying COVID-19 patients whom may rapidly deteriorate and help inform clinical management as well as hospital bed and ventilation allocation.

Clinical Characteristics and Outcomes of Patients with Coronavirus Disease 2019-associated ARDS and the Early Intubation: A Two-Hospital Retrospective Cohort Study in Hubei, China

“…We noticed that even early intubation group had 50% in-hospital mortality in the cohort, as similar as the overall global data calculated recently by the systematic review [13]. Our current ventilatory approach or intubation criteria is to delay intubation if it clinically appears safe and feasible [18]. However, the ndings of the cohort may suggest proactive intubation instead of salvage means for critical illness of COVID-19.…”

“…Analyses on retrospective data on this matter are urgently needed. In the studies published, there were a number of patients receiving intubation at one week or later after hospital admission compared with those receiving the therapy within one week [15,18]. We therefore wonder if such comparably late intubation is associated with the high mortality.…”

Discrepancies in the clinical and radiological profiles of COVID-19: A case-based discussion and review of literature

“…A study by Xiao et al [ 28 ] explored ways to objectively assess CXRs of COVID-19 positive patients at the time of admission. The authors also assessed any correlation of CXR severity and time to intubation.…”

“…Inter-rater agreement in cases of CORS ≥ 6 was noted to be moderate/substantial (κ = 0.65), suggesting the scoring system was reproducible between radiographers. The findings of this study show a reliable predictor of early intubation using an objective scoring method[ 28 ]. CORS or similar scoring criteria could have a role in reliably triaging patients with regards to planned intubation to make effective use of hospital resources such as ventilators.…”

Portable Chest Radiography as an Exclusionary Test for Adverse Clinical Outcomes During the COVID-19 Pandemic

“…17 More recent studies also have used CXR to assess COVID-19 severity and predict early intubation, continuous renal replacement therapy, and mortality. [18][19][20][21] However, public health organizations like the Centers for Disease Control and Prevention and published research largely have sought to characterize the accuracy of CXR as a diagnostic tool for COVID-19 pneumonia, concluding that it has a low specificity for diagnosis. 22 Herein, we aimed to explore the clinical usefulness of CXR as an exclusionary test for adverse clinical outcomes in patients suspected of having COVID-19.…”