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1. Monitoring of pulmonary involvement in critically ill COVID-19 patients - should lung ultrasound be preferred over CT?

Author

Arthur W. E. Lieveld, Micah L. A. Heldeweg, Jasper Schouwenburg, Lars Veldhuis, Mark E. Haaksma, Rutger M. van Haaften, Berend P. Teunissen, Jasper M. Smit, Jos Twisk, Leo Heunks, Prabath W. B. Nanayakkara, and Pieter Roel Tuinman

Subjects
COVID-19, Point-of-cafe ultrasound, Lung ultrasound, Computed tomography, Monitoring, Mortality, Medical physics. Medical radiology. Nuclear medicine, R895-920
Abstract

Abstract Background It is unclear if relevant changes in pulmonary involvement in critically ill COVID-19 patients can be reliably detected by the CT severity score (CTSS) and lung ultrasound score (LUSS), or if these changes have prognostic implications. In addition, it has been argued that adding pleural abnormalities to the LUSS could improve its prognostic value. The objective of this study was to compare LUSS and CTSS for the monitoring of COVID-19 pulmonary involvement through: first, establishing the correlation of LUSS (± pleural abnormalities) and CTSS throughout admission; second, assessing agreement and measurement error between raters for LUSS, pleural abnormalities, and CTSS; third, evaluating the association of the LUSS (± pleural abnormalities) and CTSS with mortality at different timepoints. Methods This is a prospective, observational study, conducted during the second COVID-19 wave at the AmsterdamUMC, location VUmc. Adult COVID-19 ICU patients were prospectively included when a CT or a 12-zone LUS was performed at admission or at weekly intervals according to local protocol. Patients were followed 90 days or until death. We calculated the: (1) Correlation of the LUSS (± pleural abnormalities) and CTSS throughout admission with mixed models; (2) Intra-class correlation coefficients (ICCs) and smallest detectable changes (SDCs) between raters; (3) Association between the LUSS (± pleural abnormalities) and CTSS with mixed models. Results 82 consecutive patients were included. Correlation between LUSS and CTSS was 0.45 (95% CI 0.31–0.59). ICCs for LUSS, pleural abnormalities, and CTSS were 0.88 (95% CI 0.73–0.95), 0.94 (95% CI 0.90–0.96), and 0.84 (95% CI 0.65–0.93), with SDCs of 4.8, 1.4, and 3.9. The LUSS was associated with mortality in week 2, with a score difference between patients who survived or died greater than its SDC. Addition of pleural abnormalities was not beneficial. The CTSS was associated with mortality only in week 1, but with a score difference less than its SDC. Conclusions LUSS correlated with CTSS throughout ICU admission but performed similar or better at agreement between raters and mortality prognostication. Given the benefits of LUS over CT, it should be preferred as initial monitoring tool.

Published
2023
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2. Chest CT in COVID-19 at the ED: Validation of the COVID-19 Reporting and Data System (CO-RADS) and CT severity score

Author

Arthur W.E. Lieveld, Bernd P. Teunissen, Ruud S. Kootte, Peter M. van de Ven, Sabine F.B. van der Horst, Rutger M. van Haaften, Kaoutar Azijli, Carlijn de Gans, Inge A.H. van den Berk, and Prabath W. B. Nanayakkara

Subjects
Male, PLR, positive likelihood ratio, Intraclass correlation, Chest ct, Critical Care and Intensive Care Medicine, Logistic regression, Severity of Illness Index, CUSUM, cumulative sum control chart, AUC, area under the curve, Patient Admission, 0302 clinical medicine, PCR, polymerase chain reaction, ED, Emergency department, 030212 general & internal medicine, Netherlands, Original Research, LDH, lactate dehydrogenase, Area under the curve, CO-RADS, COVID-19 Reporting and Data System, Middle Aged, Prognosis, Radiology Information Systems, NLR, negative likelihood ratio, NPV, negative predictive value, Evaluation Studies as Topic, Research Design, Radiological weapon, Emergency Medicine, CT, Computed tomography, Female, Emergency Service, Hospital, Cardiology and Cardiovascular Medicine, VUmc, Vrije Universiteit medical center, CT, Pulmonary and Respiratory Medicine, MDT, multidisciplinary team of experts, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Clinical Decision-Making, Pneumonia, Viral, CTSS, Computed tomography severity score, WHO, World Health Organization, 03 medical and health sciences, Internal medicine, ICU, Intensive Care Unit, medicine, AUROC, area under the receiver operating characteristic curve, Humans, pneumonia, FMS, Dutch Federation of Medical Specialists, Mortality, ICC, intra-class correlation coefficient, IQR, interquartile range, SARS-CoV-2, business.industry, COVID-19, RSNA, Radiological Society of North America, Triage, PPV, positive predictive value, ROC, receiver operating characteristic, CI, confidence interval, OR, odds ratio, CIE, change in estimate, 030228 respiratory system, COPD, chronic obstructive pulmonary disease, Observational study, CXR, chest radiograph, Tomography, X-Ray Computed, business, SD, standard deviation, NVvR, Radiological Society of the Netherlands
Abstract

Background: CT is thought to play a key role in coronavirus disease 2019 (COVID-19) diagnostic workup. The possibility of comparing data across different settings depends on the systematic and reproducible manner in which the scans are analyzed and reported. The COVID-19 Reporting and Data System (CO-RADS) and the corresponding CT severity score (CTSS) introduced by the Radiological Society of the Netherlands (NVvR) attempt to do so. However, this system has not been externally validated. Research Question: We aimed to prospectively validate the CO-RADS as a COVID-19 diagnostic tool at the ED and to evaluate whether the CTSS is associated with prognosis. Study Design and Methods: We conducted a prospective, observational study in two tertiary centers in The Netherlands, between March 19 and May 28, 2020. We consecutively included 741 adult patients at the ED with suspected COVID-19, who received a chest CT and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR (PCR). Diagnostic accuracy measures were calculated for CO-RADS, using PCR as reference. Logistic regression was performed for CTSS in relation to hospital admission, ICU admission, and 30-day mortality. Results: Seven hundred forty-one patients were included. We found an area under the curve (AUC) of 0.91 (CI, 0.89-0.94) for CO-RADS using PCR as reference. The optimal CO-RADS cutoff was 4, with a sensitivity of 89.4% (CI, 84.7-93.0) and specificity of 87.2% (CI, 83.9-89.9). We found a significant association between CTSS and hospital admission, ICU admission, and 30-day mortality; adjusted ORs per point increase in CTSS were 1.19 (CI, 1.09-1.28), 1.23 (1.15-1.32), 1.14 (1.07-1.22), respectively. Intraclass correlation coefficients for CO-RADS and CTSS were 0.94 (0.91-0.96) and 0.82 (0.70-0.90). Interpretation: Our findings support the use of CO-RADS and CTSS in triage, diagnosis, and management decisions for patients presenting with possible COVID-19 at the ED.

Published
2020

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