|Ahead of print publication
Initial experiences in the use of portable chest radiography as a tool to guide clinical management of COVID-19 positive patients in resource limited settings
Ojaswi Bharat Khandediya1, Dindigal Ramakrishnan Narasimhan2, Priti Kapoor3, Sagar Sinha4
1 Resident, Department of Radiology, MGM Hospital and Medical College, Navi Mumbai, Maharashtra, India
2 Resident, Department of Emergency Medicine, MGM Hospital and Medical College, Navi Mumbai, Maharashtra, India
3 Professor and Head, Department of Radiology, MGM Hospital and Medical College, Navi Mumbai, Maharashtra, India
4 Assistant Professor, Department of Emergency Medicine, MGM Hospital and Medical College, Navi Mumbai, Maharashtra, India
|Date of Submission||13-Sep-2020|
|Date of Decision||25-Sep-2020|
|Date of Acceptance||27-Dec-2020|
|Date of Web Publication||27-May-2021|
Ojaswi Bharat Khandediya,
MGM Hospital and Medical College, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Radiological diagnosis of COVID-19 has shifted from the use of routine chest X-rays (CXRs) early on during the pandemic to high-resolution computed tomography (HRCT) of the chest to accurately describe the pattern of COVID involvement of the lungs. The morphological patterns seen at HRCT are increasingly being tapped into by a clinician in the management of this uncharted territory, for example, HRCT lung findings are categorized into three distinct phenotypes by an intensivist for guiding advanced ventilatory management of COVID patients. However, in resource-limited settings, HRCT places a heavy burden on the radiology departments and poses an enormous challenge to infection control in the CT suite. Our study aims to describe CXR patterns of COVID-19 acquired by portable radiography units and correlate them to symptom onset and progression in an attempt to enroll it as a reliable tool to assist clinical management including intensive unit care and ventilatory support. Methodology: Our study was a retrospective observational study of portable CXR findings in all patients diagnosed as COVID-19 positive by reverse transcription-polymerase chain reaction at a tertiary medical center from April to May 2020. Results: A total of fifty patients were included in the study, and the presence or absence of CXR findings in the presence or absence of clinical symptoms was analyzed. Our study showed that 24 (48%) patients had baseline features of lung involvement on CXR. Patients who presented with fever or breathlessness were found to be highly likely to show changes on the CXR. The most commonly noted changes were ground-glass opacities in 31 (63%) of patients with a bilateral, peripheral pattern of involvement seen in the lower zones of the lungs. Conclusion: While the higher sensitivity of the HRCT is of great clinical value, the portable CXR offers a feasible alternative to screen, follow clinical progress, and assist management of COVID-19 patients and should be considered as a means to reduce radiological service demands and reduce the risk of cross-infection.
Keywords: Consolidation, COVID-19, computed tomography scan, ground-glass opacity, pleural effusion, radiography, X-ray
|How to cite this URL:|
Khandediya OB, Narasimhan DR, Kapoor P, Sinha S. Initial experiences in the use of portable chest radiography as a tool to guide clinical management of COVID-19 positive patients in resource limited settings. J Mar Med Soc [Epub ahead of print] [cited 2021 Jun 21]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=316986
| Introduction|| |
COVID-19, the disease caused by the SARS-CoV-2 virus, first detected in Wuhan of Hubei province in China in December 2019, initially presented as atypical pneumonia and spread at an alarming pace across the world to become a global pandemic by March 2020. The high R0 (R naught) of the virus and its ability to spread by respiratory microdroplets with significant airborne time and fomites has posed unique infection prevention control challenges.
The virus has overwhelmed major healthcare systems of the world and continues to wreak havoc across both developed and developing countries despite the imposition of a variety of public health measures to contain the spread.,
During this pandemic, the role of radiography has been crucial, right from triaging patients arriving in the flu clinic with X-rays, identifying and differentiating patient management strategies based on the early radiographic findings on chest CT, to monitoring patients' progress admitted in critical care with lung ultrasound; radiology has served as a useful tool to minimize the clinician's exposure to infected patients under his/her care. It is another matter that the protection of the radiology team poses fresh challenges that need to be dealt with innovative strategy and efforts to cut down contact time and exposure by their duty rotations and provision of adequate Personal Protective Equipment (PPE), using portable equipment, etc.
We hereby attempt to describe chest X-ray (CXR) features of patients admitted to a tertiary healthcare center in Western India and correlate the radiographic features with clinical severity of the disease.
| Methodology|| |
This is a cross-sectional study.
Patients admitted to the COVID wards/intensive care unit (ICU) at MGM Medical College and Hospital.
All patients who tested reverse transcription-polymerase chain reaction (RT-PCR) positive for SARS-CoV-2 from April 15, 2020, to May 15, 2020, were included in the study. A total of fifty patients were diagnosed as COVID-19 positive and admitted to our hospital during the study duration.
On admission or within 24 h, the patients underwent portable CXR from the suspect or positive COVID wards or ICU. This CXR allowed us to document a baseline lung involvement and allow for subsequent comparisons to be made to radiologically document disease improvement or progression.
The following patients presenting to the fever outpatient department were admitted and tested for SARS-CoV-2 by RT-PCR.
- Patients admitted with a history of travel/residence in hotspots/containment zones
- Patients with a history of contact with COVID-19–positive individuals
- Patients presenting with severe acute respiratory illness and requiring hospitalization.
All of the above patients who tested positive for SARS-CoV-2 were included in the study.
Patients who tested negative for SARS-CoV-2 by RT-PCR were excluded from the study.
X-ray details and technical factors
Portable CXR anteroposterior/posteroanterior views were performed on two 100 mA M/s Siemens' Portable Machine. The portable equipment was appropriately draped with regular surface disinfection, stringent protocols for handling cassettes followed, and aerosol decontamination by fumigation ensured at the end of the day. The two machines were dedicated for use in conducting radiographs in COVID-19–positive patients. Due to limitations of resources, we had to use a CR system, and DR system would have served better to cut down exposure to the radiographer. Every CXR was taken at 70–80 kV and 10–20 mAs on 17 inch × 14 inch cassettes. The X-rays were taken at full inspiration as far as possible with proper centering.
Methodology of reporting
The reporting was done by the doctors holding degree in radiodiagnosis and having experience of 12 years. The CXR was reported in the format of involvement of lungs, cardiac margins, mediastinum, and the bony thorax. The lungs were reported on the basis of location (upper, mid, and lower zones), distribution (peripheral, central, or diffuse), laterality (right lung, left lung, or bilateral), pattern of lesion (ground-glass opacity, fluffy opacities, consolidation, nodular, or other), associated pleural effusion, and lymphadenopathy. The term fluffy opacities were used when the opacities did not fulfill the definition of ground-glass opacity and consolidation. Precisely, the nonhomogenous opacities with diffuse or asymmetric distribution were labeled as fluffy opacities. The cardiac margins were looked for associated cardiomegaly or cardiomyopathies.
Patients underwent a portable chest radiograph during the course of admission, typically at admission, or within 24 h. This X-ray was reported by the radiology resident on duty and further verified and finalized by a radiology faculty. The findings reported in the CXR were tabulated and analyzed.
Odds ratio (OR) for the prevalence of various findings on the CXR was calculated and is also reported in the “Results” section. Data analysis was performed using SPSS version 26 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp).
Patient confidentiality was maintained by depersonalization of data during export from the PACS and analysis.
Ethical committee consent was waived by the institutional research board in view of a retrospective study.
| Results|| |
Our study duration of 1 month led to the inclusion of fifty patients between the ages of 1–75 years being included in the analysis. Among these, 32 were male (64%) and 18 were female (36%). Our study patients ranged from 1 to 75 years of age. While 18 patients were initially asymptomatic on presentation, they subsequently displayed one or more symptoms and these were included in the study.
Fever was the most commonly seen presentation in 24 patients (48%), among which twenty patients demonstrated CXR changes. The presence of fever on presentation conferred a 27 times higher likelihood of lung involvement noted on the CXR. This was closely followed by breathlessness, which was reported by 18 patients (36%) among which 16 patients showed demonstrable CXR changes. Breathlessness also conferred a high likelihood (OR = 24, confidence interval [CI] = 4.50–127.96) of changes to be noted on the CXR as compared to patients not complaining of breathlessness.
While cough, sore throat, and diarrhea were the other symptoms reported by the patients, their proportion in the study population was found to be <10% and none of these symptoms were noted to be statistically significant as far as radiological lung involvement was concerned.
Among the fifty patients in our study, only 14 admitted to being smokers. Among these, 8 (57%) were found to have CXR changes. Our study showed 17 among the fifty included patients to have comorbidities. Among our study participants, hypertension was noted to be the only statistically significant comorbidity that conferred a higher likelihood (OR = 6, CI = 1.12–31.99) of lung involvement severe enough to be noted on portable CXR films. Diabetes was reported by 8% of patients, while 4% of patients reported chronic lung disease. Neither of them was found to confer a higher likelihood of developing CXR changes when infected by SARS-CoV-2.
The features noted on the CXR are congruent with viral pneumonitis with mild variability between patients [Figure 1]. While only 48% of patients in the study showed an abnormal CXR, nearly 22% demonstrated bilateral involvement. The lower zones were the most commonly involved (42%) followed by mid-lower zone involvement. The most commonly noted pattern of involvement on the CXR was ground-glass opacities, seen in 63% of patients with any CXR changes [Figure 2], [Figure 3]. Pleural effusion and lymphadenopathy were seen in 12% of patients. These patients did not report any comorbidity.
|Figure 1: Frontal chest X- Ray showing normal lung fields and mediastinum. No significant abnormality detected|
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|Figure 2: Frontal Chest X-Ray showing non homogenous opacities in right mid zone and left lower zones peripherally suggestive of pneumonia. Mediastinum, pleura, costophrenic angles appears to be normal|
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|Figure 3: Frontal chest X-Ray showing bilateral, diffuse, non-homogenous, fluffy opacities in mid and lower zones suggestive of pneumonia with ARDS|
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| Discussion|| |
The CXR features observed in COVID-19 have been classified by Woznitza et al. as classical/probable and included bilateral involvement, lower zone predominance, ground-glass opacities, and peripheral involvement. Among these described classical features, our study demonstrated bilateral involvement in 22% of patients, lower zone predominant involvement in nearly 41% of patients, ground-glass opacities in 62% of patients, and peripheral involvement in 79% of all patients in the study. While our study included patients with a positive RT-PCR swab, the CXR findings clearly indicate the strong likelihood of a SARS-CoV-2 infection of the lungs. If obtained before the swab, or in the presence of a negative first swab, these features would suggest a clinicoradiological diagnosis of COVID-19.
These findings also correlated with those reported by Cozzi et al., Jacobi et al., and Wong et al., Shi et al.,,, Bilateral involvement was seen in 63%–79% of patients with lower zone predominance noted in all studies ranging from 27% to 63%. Ground-glass opacities were the most commonly noted radiological finding in all the above studies ranging from 41% to 65%. Peripheral involvement in the baseline CXR was noted in about 51%–57% of patients.
Our study differed from the above in having a significant number of patients with normal CXR findings. This also contributed to the lower proportions of patients with bilateral involvement and peripheral involvement as compared to the previously published literature. While Cozzi et al. reported only 5.6% normal CXRs, Yeun et al. did report a similarly high proportion and number of patients (31%, n = 64) of normal baseline CXR.,,, This is attributed to a large number of patients being mildly symptomatic, with no oxygen requirement and minimal clinical findings on respiratory examination.
While our reliance on only portable CXR to document initial radiological involvement may be dwarfed in sensitivity and accuracy by other modalities, it allowed for rigorous implementation of infection prevention and control practices in the radiology suites including the CT console. This allowed our tertiary care center to continue catering to patients who arrived for non-COVID complaints.
During the months of April and May, community transmission had not been established yet in India, and hence, most individuals who tested positive had a positive history of contact with COVID-19–positive individuals or had a history of having attended meetings/travel to hotspots., This led to a probable confounding of patient data in terms of comorbid conditions.
Although the CXR sensitivity is lower than the 97%–98% sensitivity of CT, our results suggest that CXR may play a role in early COVID-19 testing and follow-up. Although other studies are needed, in the event that there are high clinical suspicions of COVID-19, it is possible that visual CXR may eliminate the need for CT, thereby reducing the burden on CT units in the epidemic, the burden of fomite borne infection through CT suite, and high radiation exposure in morbid patients.
Moreover, the availability of CT scans at peripheral places in developing countries is another issue that needs to be addressed. During the course of this study, among the eight available radiographers, none were infected by SARS-CoV-2. While a correlation cannot be derived from that data, the value of portable CXR as a means to reduce exposure cannot be denied.
However, it was observed that the pattern of the X-ray changed with the progression of the symptoms and was helpful in triaging the patients from wards to the ICUs.
Our study has several limitations. The study is underpowered due to a smaller sample size. All patients who presented to the health center during the study duration and tested positive for SARS-CoV-2 were included in the study. We acknowledge the same and look forward to adding our findings in subsequent contributions. In addition, not all patients who were asymptomatic and showed initially normal CXR could be followed up.
As the pandemic progresses and inevitably leads to more cases, we hope to gather more data on the upcoming patients and present the same on scientific platforms to further our understanding of this disease. We hope that this case series offers a starting point for the same and allows for more studies to be performed help us all defeat a common enemy in this pandemic.
| Conclusion|| |
Our study demonstrates the utility of portable CXR as a valuable tool in resource limited settings for initial risk stratification, and measurement of disease progression. Portable CXR provides results that can be considered as a viable alternative to HRCT while reducing the risk of cross-infection during the COVID-19 pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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