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

Abstract

BACKGROUND: Chest radiography (CXR) often is performed in the acute setting to help understand the extent of respiratory disease in patients with COVID-19, but a clearly defined role for negative chest radiograph results in assessing patients has not been described.RESEARCH QUESTION: Is portable CXR an effective exclusionary test for future adverse clinical outcomes in patients suspected of having COVID-19? STUDY DESIGN AND METHODS: Charts of consecutive patients suspected of having COVID-19 at five EDs in New York City between March 19, 2020, and April 23, 2020, were reviewed. Patients were categorized based on absence of findings on initial CXR. The primary outcomes were hospital admission, mechanical ventilation, ARDS, and mortality.RESULTS: Three thousand two hundred forty-five adult patients, 474 (14.6%) with negative initial CXR results, were reviewed. Among all patients, negative initial CXR results were associated with a low probability of future adverse clinical outcomes, with negative likelihood ratios of 0.27 (95% CI, 0.23-0.31) for hospital admission, 0.24 (95% CI, 0.16-0.37) for mechanical ventilation, 0.19 (95% CI, 0.09-0.40) for ARDS, and 0.38 (95% CI, 0.29-0.51) for mortality. Among the subset of 955 patients younger than 65 years and with a duration of symptoms of at least 5 days, no patients with negative CXR results died, and the negative likelihood ratios were 0.17 (95% CI, 0.12-0.25) for hospital admission, 0.09 (95% CI, 0.02-0.36) for mechanical ventilation, and 0.09 (95% CI, 0.01-0.64) for ARDS.INTERPRETATION: Initial CXR in adult patients suspected of having COVID-19 is a strong exclusionary test for hospital admission, mechanical ventilation, ARDS, and mortality. The value of CXR as an exclusionary test for adverse clinical outcomes is highest among young adults, patients with few comorbidities, and those with a prolonged duration of symptoms.

Early radiological worsening of SARS-CoV-2 pneumonia predicts the need for ventilatory support

“…The prognostic role of imaging techniques in patients with SARS-CoV-2 pneumonia has been focused on the first CXR [ 6 – 8 , 12 ]. However, the predictive ability of the lung involvement assessed by BS on the second CXR was better in our study, probably because this follow-up better depicts the enormous capacity of COVID-19 for a rapid clinical worsening.…”

“…But it remains unclear what factors determine these differences in the course of the disease and, above all, what markers we can use to anticipate irreversible clinical deterioration. Research related to radiological prognostic markers has mainly focused on the first chest radiograph (CXR) findings [5][6][7][8]. However, there are few studies have used interval chest radiographs for prognostication of the disease [9].…”

“Rule Out” vs “Do Without”

“…In conclusion, we applaud the findings of Pagano et al 8 and wish the reader success in choosing when to "Rule Out" and when the best strategy is to "Do Without. "…”

“…7 What bearing could radiography have on excluding COVID-19? Pagano et al 8 surprised us in this issue of CHEST with an insightful analysis that evaluates the portable chest radiograph as a tool to rule out complications of COVID-19, demonstrating impressive negative likelihood ratios for admission, mechanical ventilation, the development of ARDS, and death. Their data from the Mount Sinai Health System during the New York COVID-19 surge last spring implies that a negative radiograph, especially in younger patients with few comorbidities, indicates exceedingly low-risk for severe complications.…”

COVID-19: imaging

“…Several chest radiography severity scores have been proposed as COVID-19 prognostic and monitoring tools to guide clinical decision making patients being admitted to hospital [78][79][80][81][82]. The severity of chest radiography findings based on severity scoring typically peak at days 10-13 following the onset of symptoms [78].…”