Clinical utility of chest radiography for severe COVID-19

Terrence C H Hui; Hau Wei Khoo; Barnaby E Young; Salahudeen Mohamed Haja Mohideen; Yeong Shyan Lee; Chien Joo Lim; Yee Sin Leo; Gregory J L Kaw; David C Lye; Cher Heng Tan

doi:10.21037/qims-20-642

Clinical utility of chest radiography for severe COVID-19

Quant Imaging Med Surg. 2020 Jul;10(7):1540-1550. doi: 10.21037/qims-20-642.

Authors

Terrence C H Hui¹, Hau Wei Khoo¹, Barnaby E Young^{2

3

4}, Salahudeen Mohamed Haja Mohideen⁵, Yeong Shyan Lee¹, Chien Joo Lim⁶, Yee Sin Leo^{2

3

4

7

8}, Gregory J L Kaw¹, David C Lye^{2

3

4

7}, Cher Heng Tan^{1

4}

Affiliations

¹ Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore.
² National Centre for Infectious Diseases, Singapore, Singapore.
³ Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.
⁴ Lee Kong Chian School of Medicine, Singapore, Singapore.
⁵ Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore.
⁶ Clinical Research & Innovations Office, Tan Tock Seng Hospital, Singapore, Singapore.
⁷ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁸ Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.

Abstract

Background: Chest radiography (CXR) is performed more widely and readily than CT for the management of coronavirus disease (COVID-19), but there remains little data on its clinical utility. This study aims to assess the diagnostic performance of CXR, with emphasis on its predictive value, for severe COVID-19 disease.

Methods: A retrospective cohort study was conducted, 358 chest radiographs were performed on 109 COVID-19 patients (median age 44.4 years, 58 males and 30 with comorbidities) admitted between 22 January 2020 and 15 March 2020. Each CXR was reviewed and scored by three radiologists in consensus using a 72-point COVID-19 Radiographic Score (CRS). Disease severity was determined by the need for supplemental oxygen and mechanical ventilation.

Results: Patients who needed supplemental oxygen (n=19, 17.4%) were significantly older (P<0.001) and significantly more of them had co-morbidities (P=0.011). They also had higher C-reactive protein (CRP) (P<0.001), higher lactate dehydrogenase (LDH) (P<0.001), lower lymphocyte count (P<0.001) and lower hemoglobin (Hb) (P=0.001). Their initial (CRS_initial) and maximal CRS (CRS_max) were higher (P<0.001). Adjusting for age and baseline hemoglobin, the AUROC of CRS_max (0.983) was as high as CRP_max (0.987) and higher than the AUROC for lymphocyte count_min (0.897), and LDH_max (0.900). The AUROC for CRS_initial was slightly lower (0.930). CRS_initial ≥5 had a sensitivity of 63% and specificity of 92% in predicting the need for oxygen, and 73% sensitivity and 88% specificity in predicting the need for mechanical ventilation. CRS between the 6^th and 10^th day from the onset of symptoms (CRS_D6-10) ≥5 had a sensitivity of 89% and specificity of 95% in predicting the need for oxygen, and 100% sensitivity and 86% specificity in predicting the need for mechanical ventilation.

Conclusions: Adjusting for key confounders of age and baseline Hb, CRS_max performed comparable to or better than laboratory markers in the diagnosis of severe disease. CXR performed between the 6^th and 10^th days from symptom onset was a better predictor of severe disease than CXR performed earlier at presentation. A benign clinical course was seen in CXR that were normal or had very mild abnormalities.

Keywords: Radiography; pneumonia; thoracic; viruses.