The association of chest radiographic findings and severity scoring with clinical outcomes in patients with COVID-19 presenting to the emergency department of a tertiary care hospital in Pakistan

Abstract

Introduction While chest x-rays (CXRs) represent a cost-effective imaging modality for developing countries like Pakistan, their utility for the prognostication of COVID-19 has been minimally explored. Thus, we describe the frequency and distribution of CXR findings, and their association with clinical outcomes of patients with COVID-19. Methods All adult (≥ 18 years) patients presenting between 28th February-31st May to the emergency department of a tertiary care hospital in Pakistan, who were COVID-19 positive on RT-PCR with CXR done on presentation, were included. A CXR Severity Score (CXR-SS) of 0–8 was used to quantify the extent of pulmonary infection on CXR, with a score of 0 being negative and 1–8 being positive. The patients’ initial CXR-SS and their highest CXR-SS over the hospital course were used for analysis, with cut-offs of 0–4 and 5–8 being used to assess association with clinical outcomes. Results A total of 150 patients, with 76.7% males and mean age 56.1 years, were included in this study. Initial CXR was positive in 80% of patients, and 30.7% of patients had an initial CXR-SS between 5–8. The mortality rate was 16.7% and 30.6% patients underwent ICU admission with intubation (ICU-Int). On multivariable analysis, initial CXR-SS (1.355 [1.136–1.616]) and highest CXR-SS (1.390 [1.143–1.690]) were predictors of ICU-Int, and ICU-Int was independently associated with both initial CXR-SS 5–8 (2.532 [1.109–5.782]) and highest CXR-SS 5–8 (3.386 [1.405–8.159]). Lastly, age (1.060 [1.009–1.113]), initial CXR-SS (1.278 [1.010–1.617]) and ICU-Int (5.047 [1.731–14.710]), were found to be independent predictors of mortality in our patients. Conclusion In a resource-constrained country like Pakistan, CXRs may have valuable prognostic utility in predicting ICU admission and mortality. Additional research with larger patient samples is needed to further explore the association of CXR findings with clinical outcomes.

Role of Chest X-Ray in Coronavirus Disease and Correlation of Radiological Features with Clinical Outcomes in Indian Patients

“…On logistic regression analysis, the maximum RALE score (0.0932 [0.024–0.367]) was found to be a predictor for discharge (recovery) of patients. In our study, the maximum RALE score predicted the death of patients (10.730[2.727–42.206]) ( Figure 6 ), and it was consistent with the study conducted by Kaleemi et al [ 7 ]. The CXR severity score (Brixia score, 0 to 18) designed by Borghesi et al predicted mortality in the same way [ 5 ].…”

“…Our study showed a statistically significant correlation between maximum RALE score and clinical outcome of the patients ( Table 3 ). The maximum RALE score was positively and significantly correlated with age ( r = 0.721) ( Figure 5 ), and it was consistent with the studies conducted by Kaleemi et al and Salmeron et al [ 7 , 15 ]. The maximum RALE score was positively correlated with the length of hospital stay and the death of patients, and it was consistent with the study conducted by Kaleemi et al [ 7 ].…”

“…The CXR severity score (Brixia score, 0 to 18) designed by Borghesi et al predicted mortality in the same way [ 5 ]. The maximum RALE score was found to be a predictor of length of hospital stay; Kaleemi et al observed a longer length of hospital stay among intubated patients [ 7 ]. Our study showed that the maximum RALE scores (1.258 [0.990–1.598] and 0.794 [0.625–1.009]) were predictors for a hospital stay of >10 days and ≤10 days, respectively.…”

“…The extent of lung involvement was calculated as severity score by applying Radiographic Assessment of Lung Edema (RALE) score which was suggested by Warren et al [ 8 ]. Depending on consolidation or ground-glass opacity (GGO), each CXR was given a score between 0 and 8, ranging from the absence of any involvement (score 0) to complete lung involvement on both sides (score 8) [ 4 , 6 , 7 ]: score 0; no involvement of lung parenchyma, score 1; <25% involvement of lung parenchyma, score 2; 25–50% involvement of lung parenchyma, score 3; 50–75% involvement of lung parenchyma, and score 4; >75% involvement of lung parenchyma. The RALE score for each patient was calculated from that CXR which showed maximum involvement of lung parenchyma among all CXRs performed during the hospital stay of the patient, and the final severity score (maximum RALE score) was calculated by summing of maximum scores of each lung.…”

“…This scoring system was utilized to assess its prognostic value in terms of clinical outcome of patients. Previously, this scoring system was used by Wong et al and Kaleemi et al [ 4 , 7 ]. On the basis of maximum RALE score, severity of lung involvement was classified as mild (maximum RALE score of 1-2), moderate (maximum RALE score of 3-4), severe (maximum RALE score of 5-6), and very severe (maximum RALE score of 7-8).…”