Chest X-ray in the emergency department during COVID-19 pandemic descending phase in Italy: correlation with patients' outcome

Abstract

Purpose: The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients' outcome.

Materials and methods: We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients' outcome.

Results: CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients' outcome.

Conclusion: In our study, admission CXR showed a fair specificity and a good correlation with patients' outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Keywords: COVID-19 pneumonia; Chest radiograph; Diagnosis; Emergency department.

Fig. 1

Age distribution of patients with COVID-19 pneumonia and positive nasopharyngeal swab

Fig. 2

Ground glass opacities in COVID-19 pneumonia. Figure a shows an initial interstitial thickening in both lower pulmonary lobes (arrows). In figure b, a young male patient with a diffuse basal and bilateral GGO involvement

Fig. 3

Diffuse lung involvement in COVID-19 pneumonia. Figure a shows a reticular-nodular pattern in both basal and subpleural parenchyma. Figures in b and c demonstrate diffuse lung involvement with bilateral consolidations and thickening of peri-bronchovascular interstitium

Fig. 4

Box and Whisker plot of RALE score estimated in each group by outcome: patients discharged (Group 0), patients requiring ordinary hospitalization (1), noninvasive ventilation (2) or intubation (3). RALE score showed a statistical correlation with the patients’ outcome confirming the prognostic value of CXR scores of COVID-19 involvement at the diagnosis

Fig. 5

Alternative diagnosis. In figure a, an upper-right lobar pneumonia (arrow) with diffuse inflammatory lung involvement. In figure b, an 82-year-old woman with cardiac failure and pulmonary edema, hilar congestion (arrow) and cardiomegaly