Chest imaging in

COVID-19
Iain Au-Yong, Consultant Radiologist.
Objectives
 • Reflections from first wave
• Very little known prior to first wave, preliminary data from
China (CT)
• Suggested that imaging could be used for diagnosis and
triage
• CXR preferred in Italy.

Background –
first wave • Reference:
• Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-
PCR Testing in Coronavirus Disease 2019 (COVID-19) in
China: A Report of 1014 Cases. Radiology 2020 Feb
26:200642
 • Principles:
• RT-PCR is the gold standard for diagnosis but can be false
negative (2-29%)
• Not readily available during the first wave

• Role of imaging:
• Diagnosis, for triage and management
Diagnosis of • CXR and CT are the main imaging modalities in use, US is
COVID-19 not in widespread use.

• Chest imaging has limited sensitivity and specificity.

• It should therefore be used in conjunction with clinical
suspicion and biochemical indices (such as lymphopenia)
• Prognostication
• Detection and management of complications (eg
thrombosis)
 CT
Technical • Less availability
CXR
• More availability
considerations • Disinfection more complex,
risks to staff • Portable CXR more practical,
• Additional burden of radiation disinfection more straightforward
dose and contrast
administration (AKI in COVID),
• Less sensitive. Specificity an issue
• More sensitive. Specificity an
issue
• Interpretation more
straightforward.
• Complex interpretation.
• Can provide prognostic
• Alternative diagnoses more information
readily made (PE, heart
failure)
Covid 19 NUHT Triage v 217.3.20
Suspected Diagnosis of Covid based on symptoms
Dry cough, Fatigue, Myalgia, Fever, Dyspnoea Well- Home

Unwell- ED

For Escalation?
Based on premorbid function and comorbidities* No
Discuss with Respiratory Service

F22/QMC
Yes
1st Viral PCR

+ve -ve

CT Chest*

Clear
CT features Or Pleural effusion/Pneumothorax
Peripheral multifocal airspace opacities
-Ground glass shadowing
NCH/Resp/Covid ward
-Consolidation
(Majority will have bilateral involvement)
*Escalation factors need defining
Eg not for escalation-
Chronic lung disease
Chronic heart disease
QMC/Gen Med Age criteria
NCH/Resp/Covid ward Consider second
swab
 QMC ED COVID-19 ADULT FLOW PROCESS – 2nd April
**See EDIU & inpatient pathway options below for full details of admission pathways
1. Any new cough in last 7 days
OR
2. New fever within 7 days Immediate discharge possible? Give information leaflet
OR 1. Patient looks well
3. Ambulance temperature > YES POTENTIAL 2. HR < 100 YES Provide discharge advice Home
COVID-19 3. O2 Sats > 94% (Room air)
37.7C?
(>88% in COPD) Record Obs & decision on
4. No respiratory distress MEDWAY
NO
NO YES

Does patient need High

Dependency COVID? (RESUS)
Transfer EDIU 1 or 2
Are any of the following present? • NEWS>8 Safe for discharge at Home
NO (MACU / UTU) YES
• Sneezing, Nasal discharge • Sats<92% despite HF O2 or any stage
resp distress
complete CXR & swab ASAP
or congestion
• Hoarseness or sore throat • Potential for deterioration
NO
• Dyspnoea / SOB or
wheezing YES
Consider
• Fatigue / Myalgia Can be de-escalated as NON- Admit Non-
HCOP Likely clinical YES
• Delerium / sepsis syndrome, with
COVID?? COVID ward
Are they for Pathway or QMC
unknown source NO lymphopenia &
escalation? Palliative
• D&V – (HCOP patients) care raised CRP?
YES NO

NO
NO YES Transfer to
NO
Ring Resp
CXR ? COVID ward NCH
Do they need an AGP? BATON phone
COVID & call nursing
• Cardiac Arrest COVID staff to handover
Adult - (MACU1) CTPA
NON-COVID Process Paeds – (Paeds treatment room) NOT ACCEPTED
ACCEPTED
“Resus in MAJORS” • Intubationn or CPAP/NIV YES
( MU 1-10) A – Transfer theatre / AICU if possible NEGATIVE POSITIVE NO
MT – MU 1 B - UTU Bay 11
Paeds MT – MU 5 C - MACU bay 1+9
MU Patients – MU 11-20 D – COVID Resus last option or imminent Admit Non- Admit under
YES Specialist care needed at QMC site?
Illness - GREEN arrest COVID ward speciality at QMC
(Surgery, MT, complex gastro etc.)
QMC in side room
 • Sensitivity 56% specificity 60%. (London, April 2020)
• (Borakati et al)

• However these figures vary with prevalence.

• Hot reporting

• Vvvv. Incidental COVID.

CXR

Borakati et al, BMJ Open. 2020 Nov

6;10(11):e042946.
Diagnostic accuracy of X-ray versus CT in COVID-
19: a propensity-matched database study
BSTI COVID-19 CXR Report Proforma

Findings
Normal
COVID-19 not excluded. Correlated with RT-PCR

Classic/Probable COVID-19
Lower lobe and peripheral predominant multiple opacities that are bilateral (>> unilateral)

Indeterminate for COVID-19

Does not fit Classic or Non-COVID-19 descriptors

Non-COVID-19
Pneumothorax / Lobar pneumonia / Pleural effusion(s) / Pulmonary oedema

Other

Quantifying disease

Mild / Moderate / Severe

Other findings

Codes for subsequent Radiology Information System search:

CVCX0 = Normal CVCX1 = Classic CVCX2 = Indeterminate CVCX3 = Non-COVID-19
Please consider case upload to https://bit.ly/BSTICovid19_Database
CXR Examples
Patient 1 36M
Fever SOB worsening over 8 days
?COVID

Basal and peripheral involvement

Mild

PCR +ve
• Patient 2 75M

• Presents COPD, productive cough

?COVID

• Peripheral and basal consolidation

which is bilateral.
• Classic pattern.
• Severe

• PCR subsequently positive

Patient 3. 38F

Classic pattern, severe

PCR +ve
Patient 4
36 male

Dad COVID +, unwell 11/7, dry

cough, SOB, high RR.

Lymphopenia

First swab –ve, repeat swab

+ve
Patient 5
PCR positive at time of reporting.

This film would normally be reported

as not compatible with COVID-19
Patient 8
40m
Fever
low sats ?COVID ?LRTI

Vague opacity but non specific.

Reported as normal.
Patient 8
CT performed
subsequently

RT-PCR
subsequently
confirmed
positive
 Sensitivity 85% Specificity 60% -
same study

CT
Findings: Peripheral ground
glass. Crazy paving.
Consolidation. Bronchovascular
thickening. Reverse Halos.
 • Several centres report increased incidence in an ITU setting.
Pooled analysis suggests a figure of about 17%.

• Difficult to study true prevalence. Nottingham approach and

study. Local rate about 3% in triage population

• Immunothrombosis versus embolism

Thromboembolism
in COVID • Anticoagulating all patients does not improve survival

• Criteria for diagnosing PE clinically difficult (D-dimer expected to

be raised, patients with pneumonitis have similar symptoms)

• Difficult to exclude clinically

 • Remember about renal impairment in COVID 19
• The original BSTI/NHSE algorithm remains the main stay of imaging advice, with
CTPA reasonable to perform in severely ill Covid-19 patients if the outcome would
influence initiation of therapeutic anticoagulation.
• A less severely ill patient with classic Covid-19 on CXR should not trigger a CTPA
routinely.
• CTPA in symptomatic patients with Classic Covid-19 on CXR should ideally be
reserved for ‘disproportionate hypoxia’, ‘discordant clinical picture’ or a ‘sudden
clinical deterioration’.
• This should be mentioned in all CTPA requests.
Thromboembolism • A presenting high D-Dimer in a patient with Covid-19, or an elevation/upward trend
should not solely be used to trigger a CTPA.
in COVID • At all times, patient stability and infection control considerations must be weighed
against the benefit of undertaking the CTPA, especially given the higher infectivity of
the new variant.
• When reporting CTPA the radiologist should not use the term “PE” for those with
just segmental and/or subsegmental changes but describe the changes and then
suggest they may represent PE or immunothrombosis (e.g. “a filling defect is noted;
whether or not this represents embolus or immunothrombosis is uncertain”).

• https://www.bsti.org.uk/media/resources/files/Rationale_for_CTPA_in_Covid_consi
derations_F.pdf
 • Few data.

• The prevalence of post-COVID-19 fibrosis will become

apparent in time, but early analysis from patients with
COVID-19 on discharge from hospital suggests a high rate
of fibrotic lung function abnormalities. Overall, 51 (47%) of
108 patients had impaired gas transfer and 27 (25%) had
reduced total lung capacity. This was much worse in
Post COVID patients with severe disease

fibrosis • Reference below suggests 1/3 with severe COVID-19

pneumonitis have abnormality at 6 months on imaging

• 1). Han X, Fan Y, Alwalid O, Li N, Jia X, Yuan M, Li Y, Cao

Y, Gu J, Wu H, Shi H. Six‐month follow-up chest CT findings
after severe COVID‐19 pneumonia. Radiology (In
Press) Google Scholar
 • Examples on Horos

CT
Some take
home
messages
References
• BSTI:
• https://www.bsti.org.uk/standards-clinical-guidelines/clinical-guidelines/bsti-
nhse-covid-19-radiology-decision-support-tool/
• Radiopedia article:
• https://radiopaedia.org/articles/covid-19-4?lang=gb
• Cochrane review:
• https://www.cochrane.org/CD013639/INFECTN_how-accurate-chest-imaging-
diagnosing-covid-19
• Paper on imaging findings:
• https://pubs.rsna.org/doi/10.1148/rg.2020200159
• RSNA COVID resources
• https://www.rsna.org/covid-19