Chest radiography is a poor predictor of respiratory symptoms and functional impairment in survivors of severe COVID-19 pneumonia

Abstract

Background: A standardised approach to assessing COVID-19 survivors has not been established, largely due to the paucity of data on medium- and long-term sequelae. Interval chest radiography is recommended following community-acquired pneumonia; however, its utility in monitoring recovery from COVID-19 pneumonia remains unclear.

Methods: This was a prospective single-centre observational cohort study. Patients hospitalised with severe COVID-19 pneumonia (admission duration ≥48 h and oxygen requirement ≥40% or critical care admission) underwent face-to-face assessment at 4-6 weeks post-discharge. The primary outcome was radiological resolution of COVID-19 pneumonitis (Radiographic Assessment of Lung Oedema score <5). Secondary outcomes included clinical outcomes, symptom questionnaires, mental health screening (Trauma Screening Questionnaire, seven-item Generalised Anxiety Disorder assessment and nine-item Patient Health Questionnaire) and physiological testing (4-m gait speed (4MGS) and 1-min Sit-to-Stand (STS) tests).

Results: 119 patients were assessed between June 3, 2020 and July 2, 2020 at median (interquartile range (IQR)) 61 (51-67) days post-discharge: mean±sd age 58.7±14.4 years, median (IQR) body mass index 30.0 (25.9-35.2) kg·m^-2, 62% male and 70% ethnic minority. Despite radiographic resolution of pulmonary infiltrates in 87%, modified Medical Research Council Dyspnoea (breathlessness) scale grades were above pre-COVID-19 baseline in 44%, and patients reported persistent fatigue (68%), sleep disturbance (57%) and breathlessness (32%). Screening thresholds were breached for post-traumatic stress disorder (25%), anxiety (22%) and depression (18%). 4MGS was slow (<0.8 m·s^-1) in 38% and 35% desaturated by ≥4% during the STS test. Of 56 thoracic computed tomography scans performed, 75% demonstrated COVID-19-related interstitial and/or airways disease.

Conclusions: Persistent symptoms, adverse mental health outcomes and physiological impairment are common 2 months after severe COVID-19 pneumonia. Follow-up chest radiography is a poor marker of recovery; therefore, holistic face-to-face assessment is recommended to facilitate early recognition and management of post-COVID-19 sequelae.

FIGURE 1

Patient flowchart. KCH: King's College Hospital; LOS: length of stay; F_IO2: inspiratory oxygen fraction; ICU: intensive care unit.

FIGURE 2

Relationship between modified Medical Research Council (mMRC) Dyspnoea (breathlessness) scale grade and time from hospital discharge. Black line: linear regression line (to indicate the line of best fit); grey lines: 95% CI.

FIGURE 3

Box plots of persistent symptoms and mental health and neurocognitive outcomes. PHQ-9: nine-item Patient Health Questionnaire; GAD-7: seven-item Generalised Anxiety Disorder assessment; 6-CIT: six-item Cognitive Impairment Test. a) Numerical rating scores for fatigue, breathlessness, sleep, pain and cough. b) Scores for PHQ-9, GAD-7, Trauma Screening Questionnaire and 6-CIT. Observed values are indicated by circles. Shaded boxes indicate interquartile range with median indicated by the midline and mean indicated by a diamond. The lower/upper whiskers represent the range to the minimum/maximum value or 1.5 times the median to the lower/upper quartile, whichever is highest.

FIGURE 4

Box plots of Radiographic Assessment of Lung Oedema (RALE) scores at admission, worst during hospitalisation and follow-up. Observed values are indicated by circles. Shaded boxes indicate interquartile range with median indicated by the midline and mean indicated by a diamond. The lower/upper whiskers represent the range to the minimum/maximum value or 1.5 times the median to the lower/upper quartile, whichever is highest.