Chest Radiograph Severity and Its Association With Outcomes in Subjects With COVID-19 Presenting to the Emergency Department

  1. Daniel Kotok
  2. Jose Rivera Robles
  3. Christine E Girard
  4. Shrutti K Shettigar
  5. Allen P Lavina
  6. Samantha R Gillenwater
  7. Andrew I Kim
  8. Anas Hadeh

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Abstract

Severity of radiographic abnormalities on chest radiograph in subjects with COVID-19 has been shown to be associated with worse outcomes, but studies are limited by different scoring systems, sample size, subject age, and study duration. Data regarding the longitudinal evolution of radiographic abnormalities and its association with outcomes are scarce. We sought to evaluate these questions using a well-validated scoring system (the Radiographic Assessment of Lung Edema [RALE] score) using data over 6 months from a large, multihospital health care system.

METHODS:

We collected clinical and demographic data and quantified radiographic edema on chest radiograph obtained in the emergency department (ED) as well as on days 1–2 and 3–5 (in those admitted) in subjects with a nasopharyngeal swab positive for SARS-CoV-2 by polymerase chain reaction (PCR) visiting the ED for coronavirus disease 2019 (COVID)-19-related complaints between March–September 2020. We examined the association of baseline and longitudinal evolution of radiographic edema with severity of hypoxemia and clinical outcomes.

RESULTS:

Eight hundred and seventy subjects were included (median age 53.6; 50.8% female). Inter-rate agreement for RALE scores was excellent (interclass correlation coefficient 0.84 [95% CI 0.82–0.87], P < .001). RALE scores correlated with hypoxemia as quantified by S pO 2 /F IO 2 (r = −0.42, P < .001). Admitted subjects had higher RALE scores than those discharged (6 [2–11] vs 0 [0–3], P < .001). An increase of RALE score ≥ 4 was associated with worse 30-d survival ( P = .006). Larger increases in the RALE score were associated with worse survival.

CONCLUSIONS:

The RALE score was reproducible and easily implementable in adult subjects presenting to the ED with COVID-19. Its association with physiologic parameters and outcomes at baseline and longitudinally makes it a readily available tool for prognostication and early ICU triage, particularly in patients with worsening radiographic edema.

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  1. Version published to 10.4187/respcare.09761
  2. ScreenIT

    SciScore for 10.1101/2021.10.31.21265672: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: Cleveland Clinic Institutional Review Board (IRB) exempted the study from IRB approval (FLA 20-038).
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are several limitations associated with our study. The time-frame during which the study was performed did not allow for adjustment for anti-viral treatments (such as dexamethasone and remdesivir) which have been shown to decrease severity of radiographic edema (26) as these were introduced later during the study period within the healthcare system (late August-September). We were also not able to adjust for any variables other than those obtained at baseline when performing the longitudinal analyses, raising the question of whether other organ failure outside of the pulmonary system (renal) and fluid status have contributed to radiographic deterioration that is not directly associated with COVID-19 pulmonary disease. Lastly, while the study is a multi-center study across multiple hospitals and states in the United States, practices and procedures early in the pandemic were often institution-based and not necessarily guided by the Centers for Disease Control and Prevention and/or the World Health Organization. As such, institutional standards of treatment may not have been reflective of other healthcare systems around the same time period. Despite these limitations, we excluded patients for which there was incomplete data that would otherwise require imputation and potentially affect our analyses. Instead, the study protocol structured the CXR sampling periods to provide early, standardized meaningful clinical data that may assist clinicians in prognostication and decis...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2021.10.31.21265672 on medRxiv